Virtual Interviews with Members of the Public to Assess Customer Experience with Organ Donation PSAs

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⚠️ Notice: This information collection may be referencing outdated material.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 Virtual Interviews with Members of the Public to Assess Customer Experience with Organ Donation PSAs Form and Instruction
1 Interview Guide - OMB Outreach Evaluations CLEAN.RA.docx 04.28.2020 Interview Guide - OMB Outreach Evaluations CLEAN.RA.docx Form and Instruction
04.28.2020 Recruitment Protocol - OMB Outreach Evaluation CLEAN.docx Recruitment Protocol - Outreach Evaluation IC Document
04.28.2020 Supporting Statement - OMB Outreach Evaluation CLEAN.docx Supporting Statement - Outreach Evaluation IC Document
06.17.2020 Supporting Statement - Outreach Evaluation.docx Supporting Statement - Outreach Evaluation - UPDATED IC Document

Information Collection (IC) Details

IC Title:	Virtual Interviews with Members of the Public to Assess Customer Experience with Organ Donation PSAs	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	1	Interview Guide - OMB Outreach Evaluations CLEAN.RA.docx	04.28.2020 Interview Guide - OMB Outreach Evaluations CLEAN.RA.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 32	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	32	32
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Recruitment Protocol - Outreach Evaluation	04.28.2020 Recruitment Protocol - OMB Outreach Evaluation CLEAN.docx	05/20/2020
Supporting Statement - Outreach Evaluation	04.28.2020 Supporting Statement - OMB Outreach Evaluation CLEAN.docx	05/20/2020
Supporting Statement - Outreach Evaluation - UPDATED	06.17.2020 Supporting Statement - Outreach Evaluation.docx	06/17/2020

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