Information Collection

Deceased Donor Death Referral

IC 260699 under ICR 202306-0915-003 · OMB 0915-0157.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0157 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 67 Deceased Donor Death Referral Deceased Donor Death Referral	Form and Instruction
Deceased Donor Death Referral_Instructions.docx	Instruction
Deceased Donor Death Referral_Instructions.docx	Instruction
67 Deceased Donor Death Referral Deceased Donor Death Referral.xlsx	Form and Instruction
67 Deceased Donor Death Referral Deceased Donor Death Referral.xlsx	Form and Instruction

IC Title:

Deceased Donor Death Referral

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Deceased Donor Death Referral_Instructions.docx		Yes	Yes	Fillable Fileable
Form and Instruction	67	Deceased Donor Death Referral	Deceased Donor Death Referral.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Privacy Act System of Records Notice #09-15-0055

FR Citation: 87 FR 46967

Number of Respondents: 57

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,069	3,069
Annual IC Time Burden (Hours)	1,535	1,535
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.