Report of Theft, Loss, or Release of Select Agent or Toxin (APHIS/CDC Form 3)

Possession, Use, and Transfer of Select Agents and Toxins (42 CFR 73)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0576 can be found here:

Documents and Forms

Document Name Document Type
Report of Theft, Loss, or Release of Select Agent or Toxin (APHIS/CDC Form 3) Form and Instruction
Incident Notification and Reporting APHIS/CDC Form 3 (Th Att4-Form3.pdf Form and Instruction
APHIS-CDC_Form_3_English_Fillable.pdf Drop down list IC Document

Information Collection (IC) Details

IC Title:	Report of Theft, Loss, or Release of Select Agent or Toxin (APHIS/CDC Form 3)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Incident Notification and Reporting APHIS/CDC Form 3 (Theft/Loss/Release)	Att4-Form3.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0170 National Select Agent Registry/Select Agent Transfer and Entity Registration Information System	FR Citation: 76 FR 4483

Number of Respondents: 205	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	205	-225	430
Annual IC Time Burden (Hours)	308	-122	430
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Drop down list	APHIS-CDC_Form_3_English_Fillable.pdf	12/01/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.