Donation Experience Survey

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⚠️ Notice: This information collection may be referencing outdated material.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 Donation Experience Survey Form and Instruction
1 New Survey - Be The Match Donation Experience Generic.do FORM - New Survey - Be The Match Donation Experience Generic.docx Form and Instruction
1 R Old Survey Redline - Be The Match Donation Experience Ge FORM Old Survey Redline - Be The Match Donation Experience Generic.docx Form and Instruction
06.17.2020 - Sup Statement - BeTheMatch Donation Experience CLEAN.docx Updated SS A CLEAN 6-17-20 IC Document

Information Collection (IC) Details

IC Title:	Donation Experience Survey	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	New Survey - Be The Match Donation Experience Generic.docx	FORM - New Survey - Be The Match Donation Experience Generic.docx		Yes	Yes	Fillable Fileable
Form and Instruction	1 R	Old Survey Redline - Be The Match Donation Experience Generic.docx	FORM Old Survey Redline - Be The Match Donation Experience Generic.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,625	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	1,625	1,625
Annual IC Time Burden (Hours)	218	218
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Updated SS A CLEAN 6-17-20	06.17.2020 - Sup Statement - BeTheMatch Donation Experience CLEAN.docx	06/17/2020

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