Information Collection

Att 4_ Facility Incident Reporting Form FOR POLIOVIRUS THEFT or LOSS

IC 263223 under ICR 202509-0920-009 · OMB 0920-1424.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1424 Att 4_ Facility Incident Reporting Form FOR POLIOVIRUS THEFT or LOSS	Form and Instruction
Form 0920-1424 Facility Incident Reporting Form FOR POLIOVIRUS RELEASE or POTENTIAL EXPOSURE Att 4_ Facility Incident Reporting Form FOR POLIOVIRUS THEFT or LOSS	Form and Instruction
0920-1424 Facility Incident Reporting Form FOR POLIOVIRUS RELEASE Att 4 -Theft or Loss_clean final.docx	Form and Instruction
0920-1424 Facility Incident Reporting Form FOR POLIOVIRUS RELEASE Att 4 -Theft or Loss_clean final.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1424

Is this a Common Form? No

IC Status: Modified

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	0920-1424				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: 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	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.

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