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Pancreas Transplant Program
PART 3A: Personnel – Transplant Program Director(s)
1.

Identify the Transplant Program Surgical and/or Medical Director(s) of the pancreas transplant program
(include C.V.). Briefly describe the leadership responsibilities for each.
Check
list

Question
Reference
3A 1

Required Supporting Documents
Current C.V.

Date of
Appointment

Name

Primary areas of responsibility

PART 3B, Section 1: Personnel – Surgical – Primary Surgeon
1.

Primary Pancreas Transplant Surgeon. Refer to the Bylaws for the necessary qualifications and more specific
descriptions of the required supporting documents listed below.
Check
list

Question
Reference
3B 1a

Required Supporting Documents

3B 1b

Letter from the Credentialing Committee of the applicant hospital stating that the surgeon meets all
requirements to be in good standing. Please provide an explanation of any status other than
active/full
Letter from the Surgeon detailing his/her commitment to the program and describing their
transplant experience/training.
Formal Training: A letter from training director verifying that the fellow has met the requirements.
Formal Training: A log (organized by date) of the transplant and procurement procedures.
Transplant Experience: A letter from program director verifying that the fellow has met the
requirements.
Transplant Experience: A log (organized by date) of the transplant and procurement procedures.
Other Letters of Recommendation (Reference).
Letter of recommendation attesting to the individual’s overall qualifications to act as primary
surgeon and addressing the individual’s personal integrity, honesty, familiarity with and experience
in adhering to OPTN requirements and compliance protocols, and other matters as deemed
appropriate.

3B 1c,g,h
3B 1f
3B 1f
3B 1g
3B 1g
3a

a)

Current C.V.

Name: _____________________________________________________

b) Date of Appointment (MM/DD/YY): Facility: __________ To this position: ___________
Does individual have FULL privileges at this hospital?
_____
_____

c)

Yes
No

Provide copy of hospital credentialing letter.
If the individual does not have full privileges, explain why and provide the date
the individual will be considered for full privileges. Include an explanation that
describes the scope of privileges.

Percentage of professional time spent at this facility: _______% = _____ hrs/week

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Pancreas-1

d) List below the hospitals, health care facilities, and medical group practices and percentage of
professional time this individual is on site at each:

Facility

Type

Location (city, state)

% Professional
time Spent on site

e) Board certification type (s) or equivalent. If board certification is pending, indicate the date the exam has
been scheduled. If individual has been recertified, please use that date.

Certification Type

Version date pending
Pancreas-2

Effective Date
(MM/DD/YY)

Certification Number

f)

Formal Training: List the name of the institution(s) in which pancreas and/or kidney/pancreas transplant training (residency/fellowship) was
received including Program Director(s) names, applicable dates, and the number of transplant procedures performed. Refer to the Bylaws for
the necessary qualifications and descriptions of the required supporting documents listed below unless the individual meets the pathway for post
fellowship experience as described in the requirements:
•
•

Date
From – To
MM/DD/YY
Residency:
_______ to
_______

A letter from program director verifying that the fellow has met the requirements.
A log (See Tables 1 & 2) of the transplant and procurement procedures. The log should include a patient identifier/OPTN ID Number,
transplant/procurement date and the surgeon’s role in the procedure (i.e., primary or 1st assistant). These logs must be signed by the director of the training
program.

Institution

Program
Director

# PA
Transplants as
Primary

# K/P
Transplants as
Primary

# PA
Transplants
First Assisted

# K/P
Transplants
First Assisted

# of PA
Procurements

# K/P
Procurements

Fellowship
_______ to
_______

g) Transplant Experience (Post fellowship):
List the name of the institution(s), applicable dates, and number of pancreas and/or kidney/pancreas transplants performed by the individual at each
institution. Refer to the Bylaws for the necessary qualifications and descriptions of the required supporting documents listed below.
•
•

Date
From – To
MM/DD/YY

Letter(s) of reference from the program director(s) listed below.
A log (See Tables 1 and 2) of the transplant and procurements procedures. The log should include a patient identifier/OPTN ID Number,
transplant/procurement date and the surgeon’s role in the procedure (i.e., primary or 1st assistant).
The transplant log(s) should be signed by the program director, division chief, or department chair from the program where the experience was gained.

Institution

Program
Director

# PA
Transplants as
Primary

# K/P
Transplants as
Primary

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Pancreas-3

# PA
Transplants
First Assisted

# K/P
Transplants
First Assisted

# of PA
Procurements

# K/P
Procurements

h) Summarize how the surgeon's experience fulfills the membership criteria.
(Check all that apply)
Membership Criteria
1. On site
2. Certified by the American Board of Surgery, Urology the equivalent
3. Two Year Transplant Fellowship
a. Primary Surgeon or 1st assistant on at least 15 pancreas transplants
b. Primary Surgeon or 1st assistant on 10 pancreas procurements
c. Involved in all levels of pre-, peri-, and post-operative patient care within the last 2 years
d. Training program approved by the Education Committee of the American Society of
Transplant Surgeons or UNOS
4. Experience (Post Fellowship)
a. Primary surgeon or first assist on 20 pancreas transplants over a minimum of 2 years and a
maximum of 5 years.
b. Primary surgeon or 1st assistant on 10 pancreas procurements
c. Involved in all levels of pre-, peri-, and post-operative patient care within the last 2 years.
5. Pediatric Pathway
a. Program serves predominantly Pediatric Patients
b. Demonstrate that the individual has maintained current working knowledge in all aspects
pancreas transplantation and patient care within the last 2 years.
c. Petition the MPSC for approval
d. A preliminary interview before the Committee shall be required

i)

Yes

Describe in detail the proposed primary surgeon's level of involvement in this transplant program, and if
applicable, describe the surgeon's plan for coverage of transplant programs located in multiple transplant
centers. (Expand rows below as necessary).
Describe Level of Involvement
Management of Patients
with Diabetes Mellitus
Recipient Selection
Donor Selection
Histocompatibility and
Tissue Typing
Transplant Surgery
Immediate Post-Operative
and Continuing Inpatient
Care
Post-Operative
Immunosuppressive
Therapy
Differential Diagnosis of
Pancreatic Dysfunction in
the Allograft Recipient
Histologic Interpretation of
Allograft Biopsies
Interpretation of Ancillary
Tests for Pancreatic
Dysfunction

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Describe Level of Involvement
Long-Term Outpatient
Follow-up
Coverage of Multiple
Transplant Centers (if
applicable)
Additional Information:

j)

Describe the proposed primary surgeon's transplant training and experience in the areas listed below.
(Expand rows below as necessary).
Describe Experience /Training
Management of Patients
with Diabetes Mellitus
Recipient Selection
Donor Selection
Histocompatibility and
Tissue Typing
Transplant Surgery
Immediate Post-Operative
and Continuing Inpatient
Care
Post-Operative
Immunosuppressive
Therapy
Differential Diagnosis of
Pancreatic Dysfunction in
the Allograft Recipient
Histologic Interpretation of
Allograft Biopsies
Interpretation of Ancillary
Tests for Pancreatic
Dysfunction
Long-Term Outpatient
Follow-up
Coverage of Multiple
Transplant Centers (if
applicable)
Additional Information:

Version date pending
Pancreas-5

Additional Instructions for PART 3B, Section 2: Personnel – Surgical
Complete this section of the application to describe the involvement, training, and experience of any other
surgeons participating in the program. Surgeons must be designated as Additional or Other as described
below.
The Bylaws provide the following definition of Additional Transplant Surgeon:
Additional Transplant Surgeons must be credentialed by the institution to provide transplant services and
be able to independently manage the care of transplant patients including performing the transplant
operation and procurement procedures.
Surgeons that also support this program but who do not meet the definition of “primary” or additional,” should
complete this section as well. The type should be indicated as “other.”
Duplicate pages as needed.

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PART 3B, Section 2: Personnel – Surgical
2.

List Additional/Other Surgeons (duplicate this page as needed). Provide the attachments listed below.
Check
list

Question
Reference
3B 2a
3B 2b

3B 2c,e,f

a)

Required Supporting Documents
Current C.V.
A letter from the Credentialing Committee of the applicant hospital stating that the
surgeon meets all requirements to be in good standing. Please provide an
explanation of any status other than active/full.
A letter from the Surgeon detailing his/her commitment to the program and level
of involvement in substantive patient care.

Name: _____________________________________________________________
For pancreas transplantation this individual is classified as ____Additional Surgeon
(Check only one)

___other Surgeon

b) Date of appointment (MM/DD/YY) at this Facility: ________ To this Program: _________
____
Yes
Provide copy of hospital credentialing letter.
____
No
If the individual does not have full privileges, explain why and provide the date
the individual will be considered for full privileges. Include an explanation that
describes the scope of privileges.
c)

Percentage of professional time spent on site: _______% = _____ hrs/week

d) Board certification type (s) or equivalent. If board certification is pending, indicate the date the exam has
been scheduled. If individual has been recertified, please use that date.
Effective Date
(MM/DD/YY)

Certification Type

Version date pending
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Certification Number

e)

Training (Residency/Fellowship): List the name of the institution(s) in which pancreas and/or kidney/pancreas transplant training (fellowship) was received
including Program Director(s) names, applicable dates, and the number of transplants the individual performed.

Date
From – To
MM/DD/YY
Residency:
_______ to
_______

Institution

Program
Director

# PA
Transplants
as Primary

# K/P
Transplants
as Primary

# PA
Transplants
First Assisted

# K/P Transplants
First Assisted

# of PA
Procurements

# K/P
Procurements

Fellowship
_______ to
_______

f)

Transplant Experience (Post fellowship): List the name of the institution(s), applicable dates, and number of pancreas and/or kidney/pancreas transplants
performed by the individual at each institution.
Date
From – To
MM/DD/YY

Institution

Program
Director

# PA
Transplants
as Primary

# K/P
Transplants as
Primary

Version date pending
Pancreas-8

# PA
Transplants
First Assisted

# K/P
Transplants
First Assisted

# of PA
Procurements

# K/P
Procurements

g) Describe the surgeon's level of involvement in this pancreas transplant program in the areas listed below. (Expand
rows as necessary)
Describe Level of Involvement
Management of Patients
with Diabetes Mellitus
Recipient Selection
Donor Selection
Histocompatibility and
Tissue Typing
Transplant Surgery
Immediate Post-Operative
and Continuing Inpatient
Care
Post-Operative
Immunosuppressive
Therapy
Differential Diagnosis of
Pancreatic Dysfunction in
the Allograft Recipient
Histologic Interpretation of
Allograft Biopsies
Interpretation of Ancillary
Tests for Pancreatic
Dysfunction
Long-Term Outpatient
Follow-up
Coverage of Multiple
Transplant Centers (if
applicable)
Additional Information:

Version date pending
Pancreas-9

h) Describe the surgeon's transplant training and experience in the areas listed below, (Expand rows as necessary)
Describe Level of Involvement
Management of Patients
with Diabetes Mellitus
Recipient Selection
Donor Selection
Histocompatibility and
Tissue Typing
Transplant Surgery
Immediate Post-Operative
and Continuing Inpatient
Care
Post-Operative
Immunosuppressive
Therapy
Differential Diagnosis of
Pancreatic Dysfunction in
the Allograft Recipient
Histologic Interpretation of
Allograft Biopsies
Interpretation of Ancillary
Tests for Pancreatic
Dysfunction
Long-Term Outpatient
Follow-up
Coverage of Multiple
Transplant Centers (if
applicable)
Additional Information:

Version date pending
Pancreas-10

PART 3C, Section 1: Personnel – Medical – Primary Physician
1.

Primary Pancreas Transplant Physician. Refer to the Bylaws for necessary qualifications. Provide the attachments
listed below.
Check
List

Question
Reference
3C 1a
3C 1b

Required Supporting Documents

3C 1f

Current C.V.
Letter from the Credentialing Committee of the applicant hospital stating that the physician meets
all requirements to be in good standing. Please provide an explanation of any status other than
active/full.
Letter from the Physician detailing his/her commitment to the program; level of involvement with
substantive patient care; and summarizing their previous transplant experience.
Formal Training: A letter from training director verifying that the fellow has met the requirements.

3C 1f

Formal Training: A log (See Table 3) of the transplant patients followed.

3C 1g

Transplant Experience: A letter from program director verifying that the fellow has met the
requirements.

3C 1g

Transplant Experience: A log (See Table 3) of the transplant patients followed.

3C

Other Letters of Recommendation (Reference)

3a

Letter of recommendation attesting to the individual’s overall qualifications to act as primary
physician and addressing the individual’s personal integrity, honesty, familiarity with and
experience in adhering to OPTN requirements and compliance protocols, and other matters as
deemed appropriate.

3C 1c,f,g

a) Name:______________________________________________________________
b) Date of Appointment (MM/DD/YY): Facility: __________ To this position: ___________
Does individual have FULL privileges at this hospital?
____
Yes
Provide copy of hospital credentialing letter.
____
No
If the individual does not have full privileges, explain why and provide the date the
individual will be considered for full privileges. Include an explanation that
describes the scope of privileges.
c)

Percentage of professional time on site: _______% = _____ hrs/week

d) List other hospitals, health care facilities, and medical group practices and percentage of professional time
on site at each:

Facility

Type

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Location (city, state)

% Professional
time Spent on site

e)

Board certification type (s) or equivalent. If board certification is pending, indicate the date the exam has
been scheduled. If individual has been recertified, please use that date.
Effective Date
(MM/DD/YY)

Certification Type

Version date pending
Pancreas-12

Certification Number

f)

Training (Fellowship): List the program(s) in which pancreas and/or kidney/pancreas transplant training was received including name of institution(s), Program
Director(s) names, applicable dates, and the number of transplant patients for which the physician provided substantive patient care (pre-, peri- and postoperatively from the time of transplant).
Refer to the Bylaws for the necessary qualifications and descriptions of the required supporting documents listed below unless the individual meets the pathway
for post fellowship experience as described in the requirements.
•
•

Letters from the Director of fellowship training program and the supervising qualified pancreas transplant physician verifying that the fellow has met the requirements.
A recipient log (See Table 3) that includes the date of transplant, the patient’s medical record and/or OPTN ID number. This log must be signed by the director of the
training program and/or primary transplant physician at that transplant program.

Date
From To
mm/dd/yy

Institution

Program Director

# Pancreas
Patients Followed:
Pre
Peri
Post

# Kidney/Pancreas
Patients Followed:
Pre
Peri
Post

g) Experience (Post fellowship only): List the name of the institution(s) and applicable dates, number of pancreas and/or kidney/pancreas transplants performed at
the institution for whom the Transplant Physician accepted primary responsibility for substantive patient care (pre-, peri-, and post-operatively from the time of
transplant). Refer to the Bylaws for the necessary qualifications and descriptions of the required supporting documents listed below.
•
•

Supporting letter(s) from the qualified transplant physician and/or the pancreas transplant surgeon who has been directly involved with the individual.
A recipient log (See Table 3) that includes the date of transplant, the patient’s name and/or OPTN ID number. This log should be signed by the program director,
division chief, or department chair from the program where the experience was gained.

Date
From To
mm/dd/yy

Institution

Program Director

Version date pending
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# Pancreas
Patients Followed:
Pre
Peri
Post

# Kidney/Pancreas
Patients Followed:
Pre
Peri
Post

h)

Training/Experience. Describe how the physician fulfills the requirements for participation as an observer in three
organ procurements and three pancreas transplants, as well as observing the evaluation of the donor and donor process,
and management of at least 3 multiple organ donors that include the pancreas.
•
•

Provide a log (See Table 4) of these cases that includes the date of procurement, medical record ID number and/or OPTN ID
number and the location of the donor.
If these requirements have not been met, submit a plan for how the individual will fulfill them.

Date
From To
mm/dd/yy

i)

Institution

# of PA
Procurements
Observed

# of PA
Transplants
Observed

# of PA Donors/
Donor Process

# of Multi-Organ
Donors Observed
Mgmt

Summarize how the Transplant Physician's experience fulfills the membership criteria for membership.
(Check all that apply)

Membership Criteria
1. On site
2. M.D., D.O. or equivalent degree
3. Certified by the American Board of Internal Medicine, Pediatrics or the Foreign equivalent in:
a. Nephrology
b. Endocrinology
c. Diabetology
4. Achieved eligibility in:
a. Nephrology
b. Endocrinology
c. Diabetology
5. Direct involvement in pancreas transplant patient care within the last 2 years
6. One year of specialized training in pancreas transplantation during fellowship:
a. Involved in primary care of 8 or more pancreas transplant recipients for a minimum of 3
months from the time of their transplant
b. Observed 3 organ procurement procedures and 3 pancreas transplants
c. Observed the evaluation of the donor and donor process and management of at least 3
multiple organ donors that include the pancreas
d. Fellowship Training program accredited by the RRC-IM
7. 12-month Transplant Medicine Fellowship:
a. Involved in primary care of 8 or more pancreas transplant recipients for a minimum of 3
months from the time of their transplant
b. Observed 3 procurement procedures and 3 pancreas transplants
c. Observe the evaluation of the donor and donor process, and management of at least 3
multiple organ donors which include the pancreas
d. Didactic curriculum approved by the RRC-IM
8. Experience in pancreas transplantation:
a. 2-5 years experience on an active pancreas transplant service
b. Involved in primary care of 15 or more pancreas transplant recipients for a minimum of 3
months from the time of their transplant
c. Observed 3 organ procurement procedures and 3 pancreas transplants
d. Observe the evaluation of the donor and donor process, and management of at least 3
multiple organ donors which include the pancreas
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Pancreas-14

Yes

Membership Criteria

Yes

9. Pediatric Pathway:
a. Program serves predominantly Pediatric Patients
b. Demonstrate that the individual has maintained current working knowledge in all aspects
of pancreas transplantation and patient care within the last 2 years.
c. Petition the MPSC for approval
d. A preliminary interview before the Committee shall be required
10. Conditional Pathway – Only available to Existing Programs:
a. Physician qualifying by virtue of training has been involved in the primary care of 5 or
more pancreas transplant recipients for a minimum of 3 months from the time of their
transplant
b. Physician qualifying by virtue of acquired clinical experience has been involved in the
primary care of eight or more pancreas transplant recipients for a minimum of 3 months
from the time of their transplant
c. Physician qualifying by virtue of acquired clinical experience has acquired experience
equal to 12 months on an active pancreas transplant service over a maximum of 2 years
d. Consulting relationship established with counterparts at another approved pancreas
transplant center (include letter of support)

j)

Describe in detail the proposed primary transplant physician's involvement in the management of patients in this program
and, if applicable, their plan for coverage of multiple transplant centers. (Expand rows as necessary).
Areas of Involvement in This Program

Description

Management of Patients with End Stage
Pancreas Disease
Candidate Evaluation Process
Donor Selection
Recipient Selection
Histocompatibility and Tissue Typing
Immediate Post-Operative Patient Care
Post-Operative Immunosuppressive Therapy
Differential Diagnosis of Pancreas Dysfunction
in the Allograft Recipient
Histologic Interpretation of Allograft Biopsies
Interpretation of Ancillary Tests for Pancreas
Dysfunction
Long-term Outpatient Follow-up
Additional Information

Version date pending
Pancreas-15

k)

Describe the proposed primary physician's transplant training and experience in the areas listed below. (Expand rows
as necessary)
Experience and Training

Description of Individual’s current working
knowledge in the these areas

Management of Patients with End Stage
Pancreas Disease
Candidate Evaluation Process
Donor Selection
Recipient Selection
Histocompatibility and Tissue Typing
Immediate Post-Operative Patient Care
Post-Operative Immunosuppressive Therapy
Differential Diagnosis of Pancreas Dysfunction
in the Allograft Recipient
Histologic Interpretation of Allograft Biopsies
Interpretation of Ancillary Tests for Pancreas
Dysfunction
Long-term Outpatient Follow-up
Additional Information

Version date pending
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Additional Instructions for PART 3C, Section 2: Personnel – Physicians
Complete this section of the application to describe the involvement, training, and experience of other physicians
associated with the program. Physicians must be designated as Additional or Other as described below.

The Bylaws provide the following definition of Additional Transplant Physician:
Additional Transplant Physicians must be credentialed by the institution to provide transplant services and
be able to independently manage the care of transplant patients.
Physicians that also support this program but who do not meet the definition of “primary” or “additional,” should
complete this section of the application. The type should be indicated as “other.”
Duplicate pages as needed

Version date pending
Pancreas-17

PART 3C, Section 2: Personnel – Physicians
2.

Additional/Other Physicians (Duplicate this page as needed). Refer to the Bylaws for the necessary qualifications and
descriptions of the required supporting documents listed below.
Check
list

Question
Reference
3C 2a
3C 2b

3C 2c,e,f

a)

Required Supporting Documents
Current C.V.

A letter from the Credentialing Committee of the applicant hospital stating that the
physician meets all requirements to be in good standing. Please provide an
explanation of any status other than active/full.
A letter from the Physician detailing his/her commitment to the program and level
of involvement in substantive patient care.

Name: _____________________________________________________
For pancreas transplantation this individual is classified as ____ Additional Physician ___ other Physician
(Check only one)

b)

Date of Appointment (MM/DD/YY): Facility: __________ To this position: ___________
Does individual have FULL privileges at this hospital?
_____
Yes
Provide copy of hospital credentialing letter.
_____
No
If the individual does not have full privileges, explain why and provide the date the
individual will be considered for full privileges. Include an explanation that describes the
scope of privileges.

c)

Percentage of professional time spent on site: _______% = _____ hrs/week

d)

Board certification type (s) or equivalent. If board certification is pending, indicate the date the exam has been
scheduled. If individual has been recertified, please use that date.
Effective Date
(MM/DD/YY)

Certification Type

Version date pending
Pancreas-18

Certification Number

e)

Training (Fellowship): List the program(s) in which pancreas and/or kidney/pancreas transplant training was received including name of institution(s),
Program Director(s) names, applicable dates, and the number of transplant patients followed for which the physician provided substantive care (pre-, periand post-operatively from the time of transplant).

Date
From To
mm/dd/yy

f)

Institution

Program
Director

# PANCREAS
Pts. Followed:
Pre
Peri
Post

#
KIDNEY/PANCREAS
Pts. Followed:
Pre
Peri
Post

Transplant Experience (Post fellowship only): List the name of institution(s), applicable dates, and the number of pancreas and/or kidney/pancreas
transplants performed at the institution for whom the Transplant Physician accepted primary responsibility for substantive patient care (pre-, peri- and
post-operatively from the time of transplant).

Date
From To
mm/dd/yy

Institution

Program
Director

Version date pending
Pancreas-19

# PANCREAS
Pts. Followed:
Pre
Peri
Post

#
KIDNEY/PANCREAS
Pts. Followed:
Pre
Peri
Post

g) Describe in detail the transplant physician’s involvement in this pancreas transplant program. (Expand rows as
necessary)
Areas of Involvement in this program

Description

Management of Patients with End Stage
Pancreas Disease
Candidate Evaluation Process
Donor Selection
Recipient Selection
Histocompatibility and Tissue Typing
Immediate Post-Operative Patient Care
Post-Operative Immunosuppressive Therapy
Differential Diagnosis of Pancreas Dysfunction
in the Allograft Recipient
Histologic Interpretation of Allograft Biopsies
Interpretation of Ancillary Tests for Pancreas
Dysfunction
Long-term Outpatient Follow-up
Additional Information

h) Describe the physician’s transplant training and experience in the role of transplant patient management in the
areas listed below. (Expand rows as necessary).
Areas of Involvement in this program

Description

Management of Patients with End Stage
Pancreas Disease
Candidate Evaluation Process
Donor Selection
Recipient Selection
Histocompatibility and Tissue Typing
Immediate Post-Operative Patient Care
Post-Operative Immunosuppressive Therapy
Differential Diagnosis of Pancreas Dysfunction
in the Allograft Recipient
Histologic Interpretation of Allograft Biopsies
Interpretation of Ancillary Tests for Pancreas
Dysfunction
Long-term Outpatient Follow-up
Additional Information
Version date pending
Pancreas-20

Version date pending
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PART 4: Certification of Investigation
The Bylaws state that “Each primary surgeon or primary physician, listed on the application as a part of the plan for who
shares coverage responsibility, shall submit an assessment, subject to medical peer review confidentiality requirements
and which follows guidelines provided in the application and is satisfactory to the MPSC, of all physicians and surgeons
participating in the program regarding their involvement in prior transgressions of UNOS requirements and plans to
ensure that the improper conduct is not continued.” (Emphasis Added)
a)

This hospital has conducted its own peer review of all surgeons and physicians listed below to ensure compliance
with applicable OPTN/UNOS Bylaws.
Names of Surgeons*

Names of Physicians*

b) If prior transgressions were identified has the hospital developed a plan to ensure that the improper conduct is not
continued?
____ Yes
___ No
___ Not Applicable

c) What steps will be/were taken to correct the prior improper conduct or to ensure the improper conduct is not repeated in
this program? Provide a copy of the plan.

I certify that this review was performed for each named surgeon and physician according to the hospital’s peer
review procedures.
Signature of Primary Surgeon:

Date:

Print name:
Signature of Primary Physician:

Date:

Print name:

* Expand rows as needed.
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Pancreas-22

Part 5: OPTN Staffing Report
PANCREAS TRANSPLANT PROGRAM
Member Code:

Name of Hospital:

Main Program Phone Number

Main Program Fax Number:

Toll Free Phone numbers for Patients:

Hospital #:

Hospital URL: http://www
Program #:

Answer the questions below for this transplant program. Since this information will be used to update UNETsm and the Membership Directory, make sure to include the best
(most accurate) telephone number and address for each person. Use additional pages as necessary.
Identify the Transplant Program Medical and/or Surgical Director(s):
Name

Address

Phone

Fax

Email

Phone

Fax

Email

The surgeons who participate in this transplant program are:
Name

Address

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Version date pending
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The physicians (internists) who participate in this transplant program are:
Name

Address

Phone

Fax

Email

Identify the Hospital Administrative Director/Manager who will be involved with this program: Use an * to indicate which individual will serve as the primary Transplant
Administrator if more than one.
Name

Address

Phone

Fax

Email

Phone

Fax

Email

Identify the Financial Counselor(s) who will be prominently involved with this program:
Name

Address

Version date pending
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The clinical transplant coordinators who participate in this transplant program are:
Name

Address

Phone

Fax

Email

List the data coordinators for this transplant program below. Use an * to indicate which individual will serve as the primary data coordinator.
Name

Address

Phone

Fax

Email

Phone

Fax

Email

Identify the Social Worker(s) who will be prominently involved with this program:
Name

Address

Version date pending
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Version date pending
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Identify the Pharmacist (s) who will be prominently involved with this program:
Name

Address

Phone

Fax

Email

Phone

Fax

Email

Identify the Director of Anesthesiology who will be prominently involved with this program:
Name

Address

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TABLE 1 – Primary Surgeon - Transplant Log (Sample)
Organ
Name of Proposed Primary Surgeon:
Name of hospital where transplants were
performed:
Date range of surgeon’s appointment/training:
MM/DD/YY TO MM/DD/YY
List cases listed in date order
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Date of Transplant

PT ID

Primary Surgeon

1st Assistant

Director’s Signature: ____________________________________________
Extend lines on log as needed

Version date pending
Pancreas-29

Date: ___________________

TABLE 2

Primary Surgeon - Procurement Log (Sample)

Organ
Name of Proposed Primary Surgeon:
Name of hospital where surgeons was employed
when procurements were performed:
Date range of surgeon’s appointment/training:
MM/DD/YY TO MM/DD/YY
List cases listed in date order
#

Date of
Procurement

Donor ID
Number

Location of
Donor (hospital)

Comments
(LRD/CAD/Multi-organ)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
*extend lines on log as needed
Director’s Signature: ____________________________________________

Version date pending
Pancreas-30

Date: ___________________

TABLE 3 – Primary Physician Log (1) (Sample)
List only those patients followed for 3 months from the time of transplant (including pre-, peri-, and postoperative management)
Organ
Name of Proposed Primary Physician:
Name of hospital where transplants were
performed:
Date range of surgeon’s appointment/training:
MM/DD/YY TO MM/DD/YY
List cases listed in date order
#
Date of Transplant

PT ID

Comments

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Director’s Signature: ____________________________________________
Version date pending
Pancreas-31

Date: ___________________

Extend lines on log as needed

Version date pending
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TABLE 4 Primary Physician Log (2) (Sample)
(Header should include the following information. Cases should be listed in date order)

Organ
Name of Proposed Primary Physician:
Name of hospital where transplants were
performed:
Date range of surgeon’s appointment/training:
MM/DD/YY TO MM/DD/YY
In the tables below document how the physician fulfills the requirements for participation as an observer in organ procurements and
transplants, as well as observing the selection and management of at least 3 multiple organ donors that include the organ for which
application is being submitted. List cases in date order.
Procurements Observed
#

Date of
Procurement

Medical Record/
OPTN ID #

Location of Donor (Hospital)

1
2
3
4
5
Transplants Observed
#

Date of
Transplant

Medical Record/
OPTN ID #

Location (Hospital)

1
2
3
4
5
Donor Selection and Management
#

Date of
Procurement

Medical Record/
OPTN ID #

Location of Donor
(Hospital)

1
2
3
4
5

Version date pending
Pancreas-33

Specify Organ specific
or Multi-organ?