Primary Data Coordinator Form

Organ Procurement and Transplantation Network Application Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0184 can be found here:

Documents and Forms

Document Name Document Type
Form 19 Primary Data Coordinator Form Form and Instruction
19 Primary Data Coordinator Primary Data Coordinator Form.docx Form and Instruction
19 Primary Data Coordinator Primary Data Coordinator Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Primary Data Coordinator Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	19	Primary Data Coordinator	Primary Data Coordinator Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,760	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	53	53
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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