HRSA Division of Transplanation (DoT Research on Customer Information Needs Related to Vascularized Composite Allographs Transplants

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⚠️ Notice: This information collection may be referencing outdated material.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
Form 2 HRSA Division of Transplanation (DoT Research on Customer Information Needs Related to Vascularized Composite Allographs Transplants Form and Instruction
1 Focus Groups on VCA Donation VCA_FG_Guide_3-24.15.docx Form and Instruction
2 Survey on VCA Donation VCA_Survey.doc Form and Instruction
VCA SupportingStatement.docx VCA Supporting Statement IC Document
Attachment1_FG_Informed Consent DoT.doc.doc Informed Consent IC Document
Attachment2_VCA-omb recruitmt script DoT.doc.doc Recruitment Script Screener IC Document

Information Collection (IC) Details

IC Title:	HRSA Division of Transplanation (DoT Research on Customer Information Needs Related to Vascularized Composite Allographs Transplants	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

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	2	Survey on VCA Donation	VCA_Survey.doc		Yes	Yes	Fillable Fileable
Form and Instruction	1	Focus Groups on VCA Donation	VCA_FG_Guide_3-24.15.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 724	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 97 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	724	724
Annual IC Time Burden (Hours)	174	174
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
VCA Supporting Statement	VCA SupportingStatement.docx	06/01/2015
Informed Consent	Attachment1_FG_Informed Consent DoT.doc.doc	06/01/2015
Recruitment Script Screener	Attachment2_VCA-omb recruitmt script DoT.doc.doc	06/01/2015

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