Major Breaches

Health Breach Notification Rule

Documents and Forms

Document Name Document Type
Form Not Applicable Major Breaches Form and Instruction
Not Applicable Notice of Breach of Health Information 2024.05.22 Notice of Breach of Health Information Form Reporting Form.pdf Form and Instruction
Not Applicable Notice of Breach of Health Information 2024.05.22 Notice of Breach of Health Information Form Reporting Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Major Breaches	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 16 CFR 318

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Not Applicable	Notice of Breach of Health Information	2024.05.22 Notice of Breach of Health Information Form Reporting Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	4,640	4,640
Annual IC Cost Burden (Dollars)	31,632	31,632

Documents for IC

Title	Document	Date Uploaded
No associated records found

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