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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 & A-5s)
Modified
4000
1000
0
Form
A-5
Authorization for Release of Records
Form
A-5s
Authorization for Release of Records - Spanish
Authorization for Release of Records (Form A-5 & A-5s) - Record keeping
New
4104
1368
0
Form
A-5
Authorization for Release of Records
Form
A-5s
Authorization for Release of Records - Spanish
Care Provider Facility Tour Request (Form A-1A)
Modified
200
33
0
Form
A-1A
Care Provider Facility Tour Request
Care Provider Facility Tour Request (Form A-1A) - Record Keeping
Modified
216
432
0
Form
Form A-1A
Care Provider Facility Tour Request
Emergency Significant Incident Report (Form A-10A)
Modified
3024
3024
0
Form
A-10A
Emergency Significant Incident Report - UC Path Version
Form
A-10A
Emergency SIR and Addendum - UC Portal Version
Emergency Significant Incident Report Addendum (Form A-10B)
Modified
106056
106056
0
Form
A-10B
Emergency Significant Incident Report Addendum - UC Path Version
Form
A-10B
Emergency Significant Incident Report Addendum - UC Portal Version
Event (Form A-9)
Modified
44160
7360
0
Form
A-9
Event Report
Key Personnel Minimum Qualifications Checklist and Attestation (Form A-14)
Modified
2115
353
0
Form
A-14
Key Personnel Qualification Checklist and Attestation
Notice to UAC for Flores Visits (Forms A-4 & A-4s)
Modified
20
5
0
Form
A-4
Notice to UC for Flores Visits
Form
A-4s
Notice to UC for Flores Visits - Spanish
Notification of Concern (Form A-7)
New
4500
1125
0
Form
Form A-7
Notification of Concern
ORR Waiver Request (Form A-15)
Modified
470
157
0
Form
Form A-15
ORR Waiver Request
Program Level Event (Form A-10D)
Modified
1512
1512
0
Form
A-10D
Program-Level Event Report - UC Portal Version
Form
A-10D
Program-Level Event Report and Addendum - UC Path Version
Significant Incident Report (Form A-10C)
Modified
10152
10152
0
Form
A-10C
Significant Incident Report - UC Path Version
Form
A-10C
Significant Incident Report - UC Portal Version
Total burden requested under this ICR:
180529
132577
0
To view an IC, click on IC Title