Additional Surgeon and Physician Request Form

Organ Procurement and Transplantation Network Application Form

Documents and Forms

Document Name Document Type
Form 19 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

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	19	Additional Surgeon and Physician Request Form	19_Additional Surgeon and Physician Request Form_CLEAN.docx		Yes	Yes	Fillable Fileable

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 %

	Requested	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

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.