Information Collection

Incident Report

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.