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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Authorization for Release of Records (Form A-5)
Unchanged
4000
667
0
Form
A-5
Authorization for Release of Records
Care Provider Facility Tour Request (Form A-1A)
Unchanged
200
33
0
Form
A-1A
Care Provider Facility Tour Request
Emergency Significant Incident Report (Form A-10A)
Modified
1640
547
0
Form
A-10A
Emergency Significant Incident Report
Emergency Significant Incident Report Addendum (Form A-10B)
Unchanged
1360
340
0
Form
A-10B
Emergency Significant Incident Report Addendum
Hotline Alert (Form A-12)
Unchanged
80
20
0
Form
A-12
Hotline Alert
Notice to UAC for Flores Visits (Forms A-4 & A-4s)
Unchanged
20
5
0
Form
A-4
Notice to UAC for Flores Visits
Form
A-4s
Notice to UAC for Flores Visits
Program Level Event (Form A-9)
Modified
1500
500
0
Form
A-9
Program Level Event Report
Sexual Abuse Significant Incident Report (Form A-10E)
Modified
5980
1993
0
Form
Form A-10E
Sexual Abuse Significant Incident Report
Sexual Abuse Significant Incident Report Addendum (Form A-10F)
Unchanged
4190
1048
0
Form
A-10F
Sexual Abuse Significant Incident Report Addendum
Significant Incident Report (Form A-10C)
Modified
80340
26780
0
Form
A-10C
Significant Incident Report
Significant Incident Report Addendum (Form A-10D)
Unchanged
25630
6408
0
Form
A-10D
Significant Incident Report Addendum
Total burden requested under this ICR:
124940
38341
0
To view an IC, click on IC Title