Potential Transplant Recipient

Data System for Organ Procurement and Transplantation Network

Documents and Forms

Document Name Document Type
65. Potential Transplant Recipient_Instructions.docx Instruction
65. Potential Transplant Recipient_Form_redline.xlsx Other-Redline
65 Potential Transplant Recipient 65. Potential Transplant Recipient_Form_clean.xlsx Form

Information Collection (IC) Details

IC Title:	Potential Transplant Recipient	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			65. Potential Transplant Recipient_Instructions.docx	Yes	Yes	Fillable Fileable
Form	65	Potential Transplant Recipient	65. Potential Transplant Recipient_Form_clean.xlsx	Yes	Yes	Fillable Fileable
Other-Redline			65. Potential Transplant Recipient_Form_redline.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: 304	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,829,393	376,101	1,453,292
Annual IC Time Burden (Hours)	91,470	18,805	72,665
Annual IC Cost Burden (Dollars)	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.