Additional Surgeon and Physician Request Form

Organ Procurement and Transplantation Network Application Form

OMB: 0915-0184

IC ID: 256998

Information Collection (IC) Details

View Information Collection (IC)

Additional Surgeon and Physician Request Form
 
No Unchanged
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 20 Additional Surgeon and Physician Request Form Additional Surgeon and Physician Request Form.docx Yes Yes Fillable Fileable

Health Health Care Services

 

1,562 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 125 0 0 0 0 125
Annual IC Time Burden (Hours) 146 0 0 0 0 146
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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