Information Collection

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

IC 243367 under ICR 201506-0915-001 · OMB 0915-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.