Pre-Waitlist Transplant Evaluation Form

Process Data for Organ Procurement and Transplantation Network

Documents and Forms

Document Name Document Type
Prewaitlist Eval Form Instructions.docx Instruction
2 Pre-Waitlist Transplant Evaluation Form Pre-Waitlist Transplant Evaluation Form.xlsx Form

Information Collection (IC) Details

IC Title:	Pre-Waitlist Transplant Evaluation Form	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
Instruction			Prewaitlist Eval Form Instructions.docx		Yes	Yes	Fillable Fileable
Form	2	Pre-Waitlist Transplant Evaluation Form	Pre-Waitlist Transplant Evaluation Form.xlsx		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: 248	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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	147,367	147,367
Annual IC Time Burden (Hours)	58,947	58,947
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.