Information Collection

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

IC 241075 under ICR 202409-0970-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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 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
A-9C Emergency Significant Incident Report Addendum - UC Port Non-Emergency Significant Incident Report (Form A-9C).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.