Potential Disease Transmission Report

Data System for Organ Procurement and Transplantation Network

Documents and Forms

Document Name Document Type
61. Potential Disease Transmission Report_Instructions.docx Instruction
61 Potential Disease Transmission Report_Form.xlsx 61. Potential Disease Transmission Report_Form.xlsx Form

Information Collection (IC) Details

IC Title:	Potential Disease Transmission Report	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			61. Potential Disease Transmission Report_Instructions.docx		Yes	Yes	Fillable Fileable
Form	61	Potential Disease Transmission Report_Form.xlsx	61. Potential Disease Transmission Report_Form.xlsx		Yes	Yes	Fillable Fileable

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: 56	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	621	124	497
Annual IC Time Burden (Hours)	789	158	631
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.