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