Instrument cover page

Form Approved

OMB No. 0990-xxxx

Exp. Date XX/XX/20XX

DRAFT

2012 NATIONAL TISSUE REFERRAL THROUGH UTILIZATION SURVEY (NTRUS)

The American Association of Tissue Banks, through a contract with the Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, is conducting the 2012 National Tissue Recovery through Utilization Survey (NTRUS), a cross-sectional survey of U.S. tissue banks.

TISSUE BANK: An entity/facility that provides or engages in one or more services involving tissue from

living or deceased persons for transplantation purposes. These services include obtaining authorization

and/or informed consent, assessing donor eligibility, recovery, collection, acquisition, processing,

storage, labeling, distribution and dispensing of tissue.

The data you contribute and the time you take to ensure accuracy are critical to the success of the survey. The information will be of value to tissue banks, regulators, donors, recipients and the public, and can serve multiple purposes, such as advancing tissue industry quality standards and procedures; informing public health strategic and regulatory agendas; and responding to requests from entities such as Congress, the media, and U.S. and foreign regulatory agencies for current, annual data of U.S. tissues by U.S. tissue establishments.

Please refer to the following instructions as you complete this section of the survey.

• The survey covers the period of January 1 through December 31, 2012. Please assist us by completing the online survey by date.

• Please do NOT include ocular-only and organ-only referrals or donors in this survey.

• Except where noted, all donations are for transplantation.

• Do NOT enter percentages unless requested.

• If the answer to a question is zero, it is important that your enter “0” rather than leaving the answer blank

• If you have any questions regarding the survey, please call the toll-free number at XXX or send an e-mail to xxx

Your responses are very important to us, and we appreciate your help!

Your responses will remain anonymous in the final dataset. While results of this survey will be released in aggregate form and data may be made available in the form of a de-identified dataset, no specific institutional identifiable information will be included.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer OMB No. 0990-xxxx.