Information Collection

Incident Report

IC 245425 under ICR 202404-0990-008 · OMB 0990-0477.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0990-0477 Incident Report	Form
0990-0477 Incident Report Incident Report Form 60-Day April 2024.docx oashsps.my.site.com/ohrpwebforms/s/incident-web-form	Form
0990-0477 Incident Report Incident Report Form 60-Day April 2024.docx oashsps.my.site.com/ohrpwebforms/s/incident-web-form	Form

IC Title:

Incident Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 46

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	0990-0477	Incident Report	Incident Report Form 60-Day April 2024.docx	https://oashsps.my.site.com/ohrpwebforms/s/incident-web-form	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	25	-475	500
Annual IC Time Burden (Hours)	13	-237	250
Annual IC Cost Burden (Dollars)	0	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.