Adult Heart and HeartLung Status 2 Criteria 4 Extension Justification Form Medical Urgency Data

Data System for Organ Procurement and Transplantation Network

Documents and Forms

Document Name Document Type
Form 137 Adult Heart and HeartLung Status 2 Criteria 4 Extension Justification Form Medical Urgency Data Form
137. Adult Heart and HeartLung Status 2 Criteria 4 Extension Justification Form Medical Urgency Data_Instructions.docx Instruction
137 Adult Heart and HeartLung Status 2 Criteria 4 Extension 137. Adult Heart and HeartLung Status 2 Criteria 4 Extension Justification Form Medical Urgency Data_Form.xlsx Form

Information Collection (IC) Details

IC Title:	Adult Heart and HeartLung Status 2 Criteria 4 Extension Justification Form Medical Urgency Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	137	Adult Heart and HeartLung Status 2 Criteria 4 Extension Justification Form Medical Urgency Data	137. Adult Heart and HeartLung Status 2 Criteria 4 Extension Justification Form Medical Urgency Data_Form.xlsx		Yes	Yes	Fillable Fileable
Instruction			137. Adult Heart and HeartLung Status 2 Criteria 4 Extension Justification Form Medical Urgency Data_Instructions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Privacy Act System of Records	FR Citation: 87 FR 46967

Number of Respondents: 149	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
Annual Number of Responses for this IC	454	454
Annual IC Time Burden (Hours)	286	286
Annual IC Cost Burden (Dollars)	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.