Individual Notice Written and E-mail Notice

HITECH Act Breach Notification

Documents and Forms

Document Name Document Type
0990-BreachPRA Supplementary Statement.doc 0990-BreachPRA Supplementary Statement IC Document

Information Collection (IC) Details

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

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 19,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	19,000	18,894	106
Annual IC Time Burden (Hours)	9,500	-12,336	21,836
Annual IC Cost Burden (Dollars)	1,710,000	987,822	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.