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Heart Transplant Recipient Follow Up Post 5 Year
Data System for Organ Procurement and Transplantation Network
OMB: 0915-0157
IC ID: 226418
OMB.report
HHS/HSA
OMB 0915-0157
ICR 202306-0915-003
IC 226418
( )
Documents and Forms
Document Name
Document Type
Heart Transplant Recipient Follow Up Post 5 Year_Instructions.docx
Instruction
Heart Transplant Recipient Follow Up Post 5 Year_Instructions.docx
Instruction
Heart Transplant Recipient Follow Up Post 5 Year_Form_redline.xlsx
Other-Redline
Heart Transplant Recipient Follow Up Post 5 Year_Form_redline.xlsx
Other-Redline
10 Heart Transplant Recipient Follow Up Post 5 Year_Form_Cl
Heart Transplant Recipient Follow Up Post 5 Year_Form_clean.xlsx
Form
10 Heart Transplant Recipient Follow Up Post 5 Year_Form_Cl
Heart Transplant Recipient Follow Up Post 5 Year_Form_clean.xlsx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Heart Transplant Recipient Follow Up Post 5 Year
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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
Heart Transplant Recipient Follow Up Post 5 Year_Instructions.docx
Yes
Yes
Fillable Fileable
Form
10
Heart Transplant Recipient Follow Up Post 5 Year_Form_Clean.xlsx
Heart Transplant Recipient Follow Up Post 5 Year_Form_clean.xlsx
Yes
Yes
Fillable Fileable
Other-Redline
Heart Transplant Recipient Follow Up Post 5 Year_Form_redline.xlsx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
Privacy Act System of Records Notice #09-15-0055
FR Citation:
87 FR 46967
Number of Respondents:
145
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
24,810
0
3,254
0
0
21,556
Annual IC Time Burden (Hours)
12,405
0
1,627
0
0
10,778
Annual IC Cost Burden (Dollars)
0
0
0
0
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.