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Hospital Campaign Activity Scorecard
National Hospital Organ Donation Campaign's Activity Scorecard
OMB: 0915-0373
IC ID: 209057
OMB.report
HHS/HSA
OMB 0915-0373
ICR 201809-0915-002
IC 209057
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0373 can be found here:
2020-08-21 - No material or nonsubstantive change to a currently approved collection
2019-10-10 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form 1
Hospital Campaign Activity Scorecard
Form and Instruction
Current Approved ChallengeScorecard (REDLINED).docx
Other-Redline
20180907 OMB Hospital Campaign Challenge Scorecard REDLINE.docx
Other-REDLINE
1 FINALCleanChallengeScorecard
FINALCleanChallengeScorecard.docx
Form and Instruction
2 OMB Hospital Campaign Challenge Scorecard CLEAN.docx
OMB Hospital Campaign Challenge Scorecard CLEAN.docx
Form and Instruction
0373 Hospital Campaign Change Memo CLEAN.docx
0373 Hospital Campaign Change Memo CLEAN
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Hospital Campaign Activity Scorecard
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
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
1
FINALCleanChallengeScorecard
FINALCleanChallengeScorecard.docx
Yes
Yes
Fillable Fileable
Other-Redline
Current Approved ChallengeScorecard (REDLINED).docx
Yes
Yes
Fillable Fileable
Other-REDLINE
20180907 OMB Hospital Campaign Challenge Scorecard REDLINE.docx
Yes
Yes
Fillable Fileable
Form and Instruction
2
OMB Hospital Campaign Challenge Scorecard CLEAN.docx
OMB Hospital Campaign Challenge Scorecard CLEAN.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
1,250
Number of Respondents for Small Entity:
500
Affected Public:
State, Local, and Tribal Governments
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
1,250
0
0
0
0
1,250
Annual IC Time Burden (Hours)
459
0
0
0
0
459
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
0373 Hospital Campaign Change Memo CLEAN
0373 Hospital Campaign Change Memo CLEAN.docx
09/26/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.