Att 3_ Facility Incident Reporting Form FOR POLIOVIRUS RELEASE or POTENTIAL EXPOSURE

[CPR] U.S. National Authority for Containment of Poliovirus Data Collection Tools

Documents and Forms

Document Name Document Type
Form 0920- Att 3_ Facility Incident Reporting Form FOR POLIOVIRUS RELEASE or POTENTIAL EXPOSURE Form and Instruction
0920- Facility Incident Reporting Form FOR POLIOVIRUS RELEASE Att3 - Facility Incident Reporting Form for Poliovirus Release or Potential Exposure_final.pdf Form and Instruction
0920- Facility Incident Reporting Form FOR POLIOVIRUS RELEASE Att3 - Facility Incident Reporting Form for Poliovirus Release or Potential Exposure_final.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Att 3_ Facility Incident Reporting Form FOR POLIOVIRUS RELEASE or POTENTIAL EXPOSURE	Agency IC Tracking Number:	0920-23BJ

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	0920-	Facility Incident Reporting Form FOR POLIOVIRUS RELEASE or POTENTIAL EXPOSURE	Att3 - Facility Incident Reporting Form for Poliovirus Release or Potential Exposure_final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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