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