Information Collection

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

IC 263162 under ICR 202311-0920-001 · OMB 0920-1424.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1424 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.