Be The Match Donation Experience Survey

Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Be The Match Donation Experience Survey Form and Instruction
Form 1 Be The Match Donation Experience Survey Form and Instruction
1 BTM Donation Experience Survey - CLEAN.docx Tab E - BTM Donation Experience Survey - CLEAN.docx Form and Instruction
1 BTM Donation Experience Survey - CLEAN.docx Tab E - BTM Donation Experience Survey - CLEAN.docx Form and Instruction
1A Donation Experience Survey 12272023 - Attachment A - Donation Experience Survey - Clean.docx Form and Instruction
1A Donation Experience Survey 12272023 - Attachment A - Donation Experience Survey - Clean.docx Form and Instruction
1B 12272023 - Attachment A - Redline 12272023 - Attachment A - Donation Experience Survey - Clean.docx Form and Instruction
1B 12272023 - Attachment A - Redline 12272023 - Attachment A - Donation Experience Survey - Clean.docx Form and Instruction
Tab A - Supporting Statement - CLEAN.docx Tab A - Supporting Statement - CLEAN IC Document
Tab A - Supporting Statement - CLEAN.docx Tab A - Supporting Statement - CLEAN IC Document
12272023 - Memo to OMB - Non-Substantive Change Req.docx 12272023 - Memo to OMB - Non-Substantive Change Req IC Document
12272023 - Memo to OMB - Non-Substantive Change Req.docx 12272023 - Memo to OMB - Non-Substantive Change Req IC Document

Information Collection (IC) Details

IC Title:	Be The Match Donation Experience Survey	Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	BTM Donation Experience Survey - CLEAN.docx	Tab E - BTM Donation Experience Survey - CLEAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1A	Donation Experience Survey	12272023 - Attachment A - Donation Experience Survey - Clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1B	12272023 - Attachment A - Redline	12272023 - Attachment A - Donation Experience Survey - Clean.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,672	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,672	47	1,625
Annual IC Time Burden (Hours)	217	-1	218
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Tab A - Supporting Statement - CLEAN	Tab A - Supporting Statement - CLEAN.docx	03/22/2022
12272023 - Memo to OMB - Non-Substantive Change Req	12272023 - Memo to OMB - Non-Substantive Change Req.docx	01/02/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.