Information Collection

Non-Emergency Significant Incident Report and Addendum (Form A-9C)

IC 241075 under ICR 202406-0970-006 · OMB 0970-0547.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0547 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form A-9C Non-Emergency Significant Incident Report and Addendum (Form A-9C)	Form
A-9C Emergency Significant Incident Report Addendum - UC Path SIR and Addendum (Form A-10B) - UC Path.pdf	Form
A-9C Emergency Significant Incident Report Addendum - UC Port Non-Emergency Significant Incident Report (Form A-9C).pdf	Form

IC Title:

Non-Emergency Significant Incident Report and Addendum (Form A-9C)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

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	A-9C	Emergency Significant Incident Report Addendum - UC Path Version	SIR and Addendum (Form A-10B) - UC Path.pdf		Yes	Yes	Fillable Fileable
Form	A-9C	Emergency Significant Incident Report Addendum - UC Portal Version	Non-Emergency Significant Incident Report (Form A-9C).pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: ORR Division of Children's Services Records

FR Citation: 81 FR 46682

Number of Respondents: 216

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	56,376	56,376
Annual IC Time Burden (Hours)	84,564	84,564
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.