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Additional Surgeon and Physician Request Form
Organ Procurement and Transplantation Network Application Form
OMB: 0915-0184
IC ID: 256998
OMB.report
HHS/HSA
OMB 0915-0184
ICR 202310-0915-002
IC 256998
( )
Documents and Forms
Document Name
Document Type
Form 20
Additional Surgeon and Physician Request Form
Form and Instruction
20 Additional Surgeon and Physician Request Form
Additional Surgeon and Physician Request Form.docx
Form and Instruction
20 Additional Surgeon and Physician Request Form
Additional Surgeon and Physician Request Form.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Additional Surgeon and Physician Request Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
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
20
Additional Surgeon and Physician Request Form
Additional Surgeon and Physician Request Form.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
1,562
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
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
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.