Information Collection

OPTN- Death Referral

IC 181726 under ICR 201010-0915-001 · OMB 0915-0157.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0157 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 OPTN- Death Referral	Form
2 Death Referral Data Death Referral Data Wksheet.pdf	Form
Death Referral Data Help.pdf Death Referral Instructions	IC Document
Death Referral Data Doc.pdf Death Referral Changes	IC Document

IC Title:

OPTN- Death Referral

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2	Death Referral Data	Death Referral Data Wksheet.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 58

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-696	696
Annual IC Time Burden (Hours)	-6,960	6,960
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Death Referral Instructions	Death Referral Data Help.pdf	07/17/2007
Death Referral Changes	Death Referral Data Doc.pdf	07/17/2007

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