Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Authorization for Release of Records (Form A-5) New 4000 667 0 Form A-5
Care Provider Facility Tour Request (Form A-1A) New 200 33 0 Form A-1A
Emergency Significant Incident Report (Form A-10A) New 1640 547 0 Form A-10A
Emergency Significant Incident Report Addendum (Form A-10B) New 1360 340 0 Form A-10B
Hotline Alert (Form A-12) New 80 20 0 Form A-12
Notice to UAC for Flores Visits (Forms A-4 & A-4s) New 20 5 0 Form A-4
Form A-4s
Program Level Event (Form A-9) New 1500 500 0 Form A-9
Sexual Abuse Significant Incident Report (Form A-10E) New 5980 1993 0 Form Form A-10E
Sexual Abuse Significant Incident Report Addendum (Form A-10F) New 4190 1048 0 Form A-10F
Significant Incident Report (Form A-10C) New 80340 26780 0 Form A-10C
Significant Incident Report Addendum (Form A-10D) New 25630 6408 0 Form A-10D
UAC Satisfaction Survey (Form A-11 & A-11s) New 72840 24280 0 Other-Survey
Other-Survey
UAC Satisfaction Survey Aggregate Data New 235 940 0 Form A-11 (Aggregate)
Total burden requested under this ICR: 198015 63561 0  
To view an IC, click on IC Title