Reporting the Identification of a Select Agent or Toxin from a Clinical/Diagnostic Specimen (Form 4)

Possession, Use, and Transfer of Select Agents and Toxins (42 CFR 73)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0576 can be found here:

Documents and Forms

Document Name Document Type
Form 4A Reporting the Identification of a Select Agent or Toxin from a Clinical/Diagnostic Specimen (Form 4) Form and Instruction
4A Reporting the Identification of a Select Agent or Toxin APHIS-CDC_Form_4-clean version.docx Form and Instruction
4A Reporting the Identification of a Select Agent or Toxin APHIS-CDC_Form_4-clean version.docx Form and Instruction
0920-0576 Reporting the Identification of a Select Agent or Toxin APHIS-CDC_Form_4-clean version.docx Form and Instruction
0920-0576 Reporting the Identification of a Select Agent or Toxin APHIS-CDC_Form_4-clean version.docx Form and Instruction
APHIS-CDC_Form_4-tracked changes.docx Minor Changes to Form 4 (March 2022) IC Document
APHIS-CDC_Form_4-tracked changes.docx Minor Changes to Form 4 (March 2022) IC Document

Information Collection (IC) Details

IC Title:	Reporting the Identification of a Select Agent or Toxin from a Clinical/Diagnostic Specimen (Form 4)	Agency IC Tracking Number:	0920-0576 18FL

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4A	Reporting the Identification of a Select Agent or Toxin from a Clinical/Diagnostic Specimen	APHIS-CDC_Form_4-clean version.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0576	Reporting the Identification of a Select Agent or Toxin from a Clinical/Diagnostic Specimen	APHIS-CDC_Form_4-clean version.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0170 National Select Agent Registry/Select Agent Transfer and Entity Registration Information System	FR Citation: 76 FR 4483

Number of Respondents: 1,181	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,181	1,181
Annual IC Time Burden (Hours)	1,181	1,181
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Minor Changes to Form 4 (March 2022)	APHIS-CDC_Form_4-tracked changes.docx	03/21/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.