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Individual Notice Written and E-mail Notice
HITECH Act Breach Notification
OMB: 0990-0346
IC ID: 190795
OMB.report
HHS/HHSDM
OMB 0990-0346
ICR 201001-0990-001
IC 190795
( )
Documents and Forms
Document Name
Document Type
0990-BreachPRA Supplementary Statement.doc
0990-BreachPRA Supplementary Statement
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Individual Notice Written and E-mail Notice
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
45 CFR 160
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
106
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
106
0
0
0
0
106
Annual IC Time Burden (Hours)
21,836
0
0
0
0
21,836
Annual IC Cost Burden (Dollars)
722,178
0
0
0
0
722,178
Documents for IC
Title
Document
Date Uploaded
0990-BreachPRA Supplementary Statement
0990-BreachPRA Supplementary Statement.doc
12/23/2009
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
