Discussion on Teen Organ Donors

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⚠️ Notice: This information collection may be referencing outdated material.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 1 Discussion on Teen Organ Donors Form and Instruction
1 Attachment 1 Focus Group Informed Consent 20160324 Attachment 1_Focus Group Informed Consent_FinalDraft.docx Form and Instruction
2 Attachment 2 Focus Group Participant Screener 20160324 Attachment 2__FocusGroup_ParticipantScreener_FinalDraft.docx Form and Instruction
3 Attachment 4 Survey Screener and Questionnaire 20160324 Attachment 4_Survey _Screener and Questionnaire_FinalDraft.docx Form and Instruction
SupportingStatement_TeenDonor_FinalDraft.docx Supporting Statement IC Document
Attachment 3 _FocusGroup_ModeratorGuide_FinalDraft.docx Attachment 3 - Focus Group Moderator Guide IC Document
IRB Question.msg IRB Question IC Document

Information Collection (IC) Details

IC Title:	Discussion on Teen Organ Donors	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?	Electronic Capability
Form and Instruction	1	Attachment 1 Focus Group Informed Consent	20160324 Attachment 1_Focus Group Informed Consent_FinalDraft.docx	No	Paper Only
Form and Instruction	2	Attachment 2 Focus Group Participant Screener	20160324 Attachment 2__FocusGroup_ParticipantScreener_FinalDraft.docx	No	Paper Only
Form and Instruction	3	Attachment 4 Survey Screener and Questionnaire	20160324 Attachment 4_Survey _Screener and Questionnaire_FinalDraft.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 124	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	124	124
Annual IC Time Burden (Hours)	71	71
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	SupportingStatement_TeenDonor_FinalDraft.docx	06/10/2016
Attachment 3 - Focus Group Moderator Guide	Attachment 3 _FocusGroup_ModeratorGuide_FinalDraft.docx	06/10/2016
IRB Question	IRB Question.msg	06/10/2016

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