Information Collection

Pre-Mortem Donor Recruitment Form

IC 215924 under ICR 201507-0925-001 · OMB 0925-0723.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0723 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Pre-Mortem Donor Recruitment Form Form and Instruction
1 Pre-Mortem Donor Recruitment Form Att 2 - Pre-Mortem Donor Recruitment Formv2.pdf Form and Instruction
Att 1 - Neurobiobank Tissue Access Policy Final 112613.pdf Attachment 1 Neurobiobank Tissue Access Policy IC Document
Contact Info for NeuroBioBank Tissue Access Committee Members.docx Contact Info for NeuroBioBank Tissue Access Committe Members IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pre-Mortem Donor Recruitment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	Pre-Mortem Donor Recruitment Form	Att 2 - Pre-Mortem Donor Recruitment Formv2.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 1 Neurobiobank Tissue Access Policy	Att 1 - Neurobiobank Tissue Access Policy Final 112613.pdf	04/01/2015
Contact Info for NeuroBioBank Tissue Access Committe Members	Contact Info for NeuroBioBank Tissue Access Committee Members.docx	04/01/2015

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