HRSA Division of Transplantation Qualitative Assessment of Outreach Materials

Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Document Name Document Type
Attachment1_Informed Consent_interview.doc Instruction
Attachment2_Informed Consent_focusgroup.doc Instruction
1 Screener Interview Attachment3_Screener_interview.doc Form
2 Screener focusgroup Attachment4_Screener_focusgroup.doc Form
3 Interview Guide Attachment5_InterviewGuide.docx Form
4 Focus Group Guide Attachment6_FocusGroupGuide.doc Form
HRSA-DOT-SupportingStatementOrganDonation final.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	HRSA Division of Transplantation Qualitative Assessment of Outreach Materials	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attachment1_Informed Consent_interview.doc	Yes	No	Printable Only
Instruction			Attachment2_Informed Consent_focusgroup.doc	Yes	No	Printable Only
Form	1	Screener Interview	Attachment3_Screener_interview.doc	Yes	No	Printable Only
Form	2	Screener focusgroup	Attachment4_Screener_focusgroup.doc	Yes	No	Printable Only
Form	3	Interview Guide	Attachment5_InterviewGuide.docx	Yes	No	Printable Only
Form	4	Focus Group Guide	Attachment6_FocusGroupGuide.doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 223	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	223	0	0	0	0	0
Annual IC Time Burden (Hours)	383	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	HRSA-DOT-SupportingStatementOrganDonation final.docx	01/30/2012

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