Information Collection

Additional Surgeon and Physician Request Form

IC 256998 under ICR 202512-0915-001 · OMB 0915-0184.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 19 Additional Surgeon and Physician Request Form	Form and Instruction
Form 19 Additional Surgeon and Physician Request Form Additional Surgeon and Physician Request Form	Form and Instruction
19 Additional Surgeon and Physician Request Form 19_Additional Surgeon and Physician Request Form_CLEAN.docx	Form and Instruction
19 Additional Surgeon and Physician Request Form 19_Additional Surgeon and Physician Request Form_CLEAN.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: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	19				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Organ Procurement and Transplantation Network (OPTN)/ Scientific Registry of Transplant Recipients (SRTR) Data System, HHS/ HRSA/HSB/DoT, 09-15-0055

FR Citation: 87 FR 46967

Number of Respondents: 839

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	311	186	125
Annual IC Time Burden (Hours)	261	115	146
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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