HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach

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⚠️ Notice: This information collection may be referencing outdated material.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 HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach Form and Instruction
FORM Focus Group Screener - CLEAN.docx Other-Screener
1 FORM Focus Group CLEAN.docx FORM Focus Group CLEAN.docx Form and Instruction
2 FORM Survey Questions CLEAN.docx FORM Survey Questions CLEAN.docx Form and Instruction
FINAL Supporting Statement - Formative Eval Minority Outreach Generic.docx Supporting Statement A IC Document

Information Collection (IC) Details

IC Title:	HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach	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?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	FORM Focus Group CLEAN.docx	FORM Focus Group CLEAN.docx	Yes	Yes	Fillable Fileable
Other-Screener			FORM Focus Group Screener - CLEAN.docx	Yes	No	Paper Only
Form and Instruction	2	FORM Survey Questions CLEAN.docx	FORM Survey Questions CLEAN.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 896	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	896	896
Annual IC Time Burden (Hours)	301	301
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	FINAL Supporting Statement - Formative Eval Minority Outreach Generic.docx	08/28/2020

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