Information Collection

Deceased Donor Death Referral

IC 260699 under ICR 202506-0915-004 · OMB 0915-0157.

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
67. Deceased Donor Death Referral_Instructions.docx	Instruction
67. Deceased Donor Death Referral_Instructions.docx	Instruction
67. Deceased Donor Death Referral_Form_redline.xlsx	Other-Redline
67. Deceased Donor Death Referral_Form_redline.xlsx	Other-Redline
67 Deceased Donor Death Referral 67. Deceased Donor Death Referral_Form_clean.xlsx	Form
67 Deceased Donor Death Referral 67. Deceased Donor Death Referral_Form_clean.xlsx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	Yes	Fillable Fileable
Form	67	Yes	Yes	Fillable Fileable
Other-Redline		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: 56

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	Previously Approved
Annual Number of Responses for this IC	3,254	185	3,069
Annual IC Time Burden (Hours)	1,627	92	1,535
Annual IC Cost Burden (Dollars)	0	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.

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