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