Information Collection

5. OPTN Ad Hoc Conflict-of-Interest Form

IC 283294 under ICR 202610-0906-005 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Form 5. OPTN Ad Hoc Conflict-of-Interest Form - 0906-NEW - 10.21.2026 5. OPTN Ad Hoc Conflict-of-Interest Form	Form and Instruction
5 Form 5. OPTN Ad Hoc Conflict-of-Interest Form - 0906-NEW Form 5. OPTN Ad Hoc Conflict-of-Interest Form - 0906-NEW - 10.21.2026.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 121.3(a)

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	5				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: HHS Correspondence, Customer Service, and Contact List Records

FR Citation: 86 FR 12699

Number of Respondents: 74

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,776	1,776
Annual IC Time Burden (Hours)	142	142
Annual IC Cost Burden (Dollars)	13,856	13,856

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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