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

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

Question
Reference
3A 1

Name

Required Supporting Documents
Current C.V.

Date of
Appointment

Primary areas of responsibility

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

Primary Heart 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
3B 1b
3B 1c, f, g
3B 1f
3B 1f
3B 1g
3B 1g
3B
4a

a)

Required Supporting Documents
Current C.V.
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 the training director verifying that the fellow has met the requirements
Formal Training: A log (See Tables 1 & 2) of the transplant and procurement procedures.
Transplant Experience: A letter from the program director verifying that the individual has met the
requirements
Transplant Experience: A log (See Tables 1 & 2) 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.

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)

Version date pending

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

Heart - 1

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

Facility

e)

Type

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

Location (City, State)

% Professional
Time Spent on
Site

Heart - 2

Effective Date
(MM/DD/YY)

Certification Number

f)

Formal Training: List the name of the institution(s) in which heart transplant training (residency/fellowship) was received including Program
Director(s) names, applicable dates, and the number of transplant and procurement 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:
•
•

A letter from the program director verifying that the fellow has met the requirements.
A log (organized by date) 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.

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

# Transplants as
Primary
Institution

Program Director

HR

HL

# Transplants First
Assisted
HR

HL

# of
Procurements
HR

HL

Fellowship
_______ to
_______

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

Letter(s) of reference from the program director(s) listed below.
A log (organized by date) 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).
The transplant log(s) 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

Version date pending

# Transplants as
Primary
Institution

Heart - 3

Program Director

HR

HL

# Transplants First
Assisted
HR

HL

# of
Procurements
HR

HL

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 Thoracic Surgery or the equivalent
3. Cardiothoracic Surgery Residency
a. Primary surgeon or 1st assistant on 20 or more heart and/or heart/lung transplants
b. Primary Surgeon or 1st assistant on 10 or more heart or heart/lung procurements
c. Involved in all levels of pre-, peri-, and post-operative patient care within the last 2 years
d. Training program approved by American Board of Thoracic Surgery
4. 12-month Heart Transplant Fellowship
a. Primary surgeon or 1st assistant on 20 or more heart and/or heart/lung transplants
b. Primary surgeon or 1st assistant on 10 or more heart or heart/lung procurements
c. Involved in all levels of pre-, peri-, and post-operative patient care within the last 2 years
d. Training program approved by American Board of Thoracic Surgery
5. Experience (Post Fellowship)
a. Primary surgeon or 1st assistant on 20 or more heart and/or heart/lung transplants
over a minimum of 2 years and a maximum of 5 years. Of these 20 transplants, at
least 15 were performed as primary surgeon
b. Primary surgeon or 1st assistant on 10 or more heart or heart/lung procurements
c. Involved in all levels of pre-, peri-, and post-operative patient care within the last 2 years
6. Pediatric Pathway
a. Program serves predominantly pediatric patients
b. Individual has maintained current working knowledge in all aspects of heart
transplantation and patient care within the last 2 years.
c. Center has petitioned the Membership and Professional Standards Committee for approval
under this pathway
d. A preliminary interview before the Membership and Professional Standards Committee
shall be required

Version date pending

Heart - 4

Yes

i)

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
Pre-Operative Patient
Management
Recipient Selection
Donor Selection
Transplant Surgery
Post-Operative
Hemodynamic Care
Use of Mechanical Assist
Devices
Post-Operative
Immunosuppressive
Therapy
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
Pre-Operative Patient
Management
Recipient Selection
Donor Selection
Transplant Surgery
Post-Operative
Hemodynamic Care
Post-Operative
Immunosuppressive
Therapy
Use of Mechanical Assist
Devices
Outpatient Follow-up
Additional Information

Version date pending

Heart - 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.

Version date pending

Heart - 6

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

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

Question
Reference
3B 2a
3B 2b

3B 2c,e,f

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.

a) Name: _____________________________________________________________
For heart transplantation this individual is classified as ____ Additional Surgeon
(Check only one)
b) Date of appointment (MM/DD/YY): Facility: ____________

___ other Surgeon

To this Program: _________

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.

Certification Type

Version date pending

Heart - 7

Effective Date
(MM/DD/YY)

Certification Number

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

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

# Transplants as
Primary
Institution

Program Director

HR

HL

# Transplants First
Assisted
HR

HL

# of
Procurements
HR

HL

Fellowship
_______ to
_______

f)

Transplant Experience (Post fellowship): List the name of the institution(s), applicable dates, and number of heart and/or heart/lung transplants and procurements
performed by the individual at each institution.

Date
From – To
MM/DD/YY

Version date pending

# Transplants as
Primary
Institution

Heart - 8

Program Director

HR

HL

# Transplants
First Assisted
HR

HL

# of
Procurements
HR

HL

g) Describe the surgeon's level of involvement in this heart transplant program in the areas listed below. (Expand rows
as necessary)
Describe Level of Involvement
Pre-Operative Patient
Management
Recipient Selection
Donor Selection
Transplant Surgery
Post-Operative
Hemodynamic Care
Post-Operative
Immunosuppressive
Therapy
Use of Mechanical Assist
Devices
Outpatient follow-up
Additional Information

h) Describe the surgeon's heart transplant training and experience in the areas listed below. (Expand rows as necessary)
Describe Experience/Training
Pre-Operative Patient
Management
Recipient Selection
Donor Selection
Transplant Surgery
Post-Operative
Hemodynamic Care
Post-Operative
Immunosuppressive
Therapy
Use of Mechanical Assist
Devices
Outpatient follow-up
Additional Information

Version date pending

Heart - 9

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

Primary Heart Transplant Physician. Refer to the Bylaws for necessary qualifications. Provide the attachments
listed below:
Check
list

Question
Reference
3C 1a
3C 1b
3C 1c,f,g
3C 1f
3C 1f
3C 1g
3C 1g
3C

4a

Required Supporting Documents
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 the training director verifying that the fellow has met the
requirements
Formal Training: A log (See Table 3) of the transplant recipients followed.
Transplant Experience: A letter from the program director verifying that the individual has met the
requirements
Transplant Experience: A log (See Table 3) of the transplant recipients followed.
Other Letters of Recommendation (Reference)
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

a) 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 on site: _______% = _____ hrs/week

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

Facility

Version date pending

Type

Heart - 10

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

Heart - 11

Effective Date
(MM/DD/YY)

Certification Number

f)

Training (Fellowship): List the program(s) in which heart transplant training was received including name of institution(s), Program Director(s) names, applicable
dates, and the number of transplant patients for whom the physician provided 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 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 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

# Heart Patients
Followed:
Pre
Peri
Post

# Heart/Lung Patients
Followed:
Pre
Peri
Post

g) Experience (Post fellowship only): List the name of the institution(s), Program Director(s), applicable dates, and number of heart and/or heart/lung 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.
•

•

A supporting letter from either the heart transplant physician or the heart transplant surgeon at the cardiologist’s institution with whom the cardiologist has been directly
involved, who can certify the cardiologist’s competence.
A recipient log (See Table 3) that includes the date of transplant, and 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

Version date pending

Institution

Heart - 12

Program Director

# Heart Patients
Followed:
Pre
Peri
Post

# Heart/Lung 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 transplants that include the heart, as well as observing the evaluation of the donor and
donor process, and management of at least 3 multiple organ donors which include the heart and/or heart/lung.
•

•

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 explaining how the individual will fulfill them.

Date
From To
mm/dd/yy

i)

Institution

# of HR
Procurements
Observed

# of HR
Transplants
Observed

# of HR Donors/
Donor Process

# of MultiOrgan Donors
Observed
Mgmt.

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

Membership Criteria
On site
M.D., D.O. or equivalent degree
Certified by the American Board of Internal Medicine, Pediatrics or the equivalent
Board certified in Cardiology
Achieved eligibility in Cardiology
Cardiology Fellowship
a. Involved in the primary care of 20 or more heart and/or heart/lung transplant recipients
from the time of their transplant
b. Experience with pre-, peri-, and post-operative patient care within the last 2 years
c. Observed 3 procurement procedures and 3 heart transplants
d. Observed the evaluation of the donor and donor process, and management of at least 3
multiple organ donors which include the heart and/or heart/lung
e. Fellowship training program certified by American Board of Internal Medicine (adult
cardiology) or American Board of Pediatrics (pediatric cardiology), or accepted as
equivalent by MPSC (foreign training)
7. 12-month Transplant Cardiology Fellowship
a. Involved in the primary care of 20 or more heart and/or heart/lung transplant recipients
from the time of transplant
b. Experience with pre-, peri-, and post-operative care within the last 2 years
c. Observed 3 procurement procedures and 3 heart transplants
d. Observed the evaluation of the donor and donor process, and management of at least 3
multiple organ donors which include the heart and/or heart/lung
e. Fellowship training program certified by American Board of Internal Medicine (adult
cardiology) or American Board of Pediatrics (pediatric cardiology), or accepted as
equivalent by the Membership and Professional Standards Committee (foreign training)
8. Acquired clinical experience in heart and/or heart/lung transplantation
a. 2-5 years experience on an active heart transplant service
b. Involved in the primary care of 20 or more heart and/or heart/lung transplant recipients
for a minimum of 3 months from the time of their transplant
c. Experience with pre-, peri-, and post-operative care within the last 2 years
d. Observed 3 procurement procedures and 3 heart transplants
e. Observed the evaluation of the donor and donor process, and management of at least 3
multiple organ donors which include the heart and/or heart/lung
Version date pending
Heart - 13
1.
2.
3.
4.
5.
6.

Yes

Membership Criteria
9. Pediatric Pathway
a. Program serves predominantly pediatric patients
b. Individual has maintained current working knowledge in all aspects of heart
transplantation and patient care within the last 2 years.
c. Center has petitioned the Membership and Professional Standards Committee for approval
under this pathway
d. A preliminary interview before the Membership and Professional Standards Committee
shall be required
10. Conditional Pathway – Only available to Existing Programs
a. Qualifying by virtue of training
i. Involved in the primary care of 10 or more heart or heart/lung transplant recipients
from the time of their transplant
ii. Training center conducts 20 or more heart or heart/lung transplants per year
b. Qualifying by virtue of acquired clinical experience
i. Involved in the primary care of 10 or more heart or heart/lung transplant recipients for
a minimum of 3 months from the time of their transplant
ii. Acquired a minimum of 12 months experience on an active heart transplant service
over a maximum of 2 years
c. Consulting relationship with counterparts at another UNOS member transplant center
approved for heart transplantation (include letter of support).

Version date pending

Heart - 14

Yes

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

Candidate Evaluation Process
Pre- and Post-Operative Hemodynamic Care
Post-Operative Immunosuppressive Therapy
Long-term Outpatient Follow-up
Care of Acute and Chronic Heart Failure
Use of Mechanical Assist Devices
Donor Selection
Recipient Selection
Histologic Interpretation and Grading of
Myocardial Biopsies for Rejection
Coverage of Multiple Transplant Centers (if
applicable)
Additional Information

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

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

Candidate Evaluation Process
Pre- and Post-Operative Hemodynamic Care
Post-Operative Immunosuppressive Therapy
Long-term Outpatient Follow-up
Care of Acute and Chronic Heart Failure
Use of Mechanical Assist Devices
Donor Selection
Recipient Selection
Histologic Interpretation and Grading of
Myocardial Biopsies for Rejection
Additional Information

Version date pending

Heart - 15

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

Heart - 16

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

List 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

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.

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 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.

Certification Type

Version date pending

Heart - 17

Effective Date
(MM/DD/YY)

Certification Number

e)

Training (Fellowship): List the program(s) in which heart transplant training was received including name of institution(s), Program Director(s) names,
applicable dates, and the number of transplant patients for whom the physician provided substantive patient care (pre-, peri- and post-operatively from the time
of transplant).
Date
From To
mm/dd/yy

f)

Institution

Program Director

# Heart Patients
Followed
Pre
Peri
Post

# Heart/Lung Patients
Followed
Pre
Peri
Post

Transplant Experience (Post fellowship only): List the name of the institution(s), Program Director(s), applicable dates, and number of heart and/or heart/lung
transplants performed at the institution for whom the Transplant Physician accepted primary responsibility for substantive patient care (pre-, peri-, and postoperatively from the time of transplant).
Date
From To
mm/dd/yy

Version date pending

Institution

Heart - 18

Program Director

# Heart Patients
Followed
Pre
Peri
Post

# Heart/Lung Patients
Followed
Pre
Peri
Post

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

Description

Candidate Evaluation Process
Pre- and Post-Operative Hemodynamic Care
Post-Operative Immunosuppressive Therapy
Long-term Outpatient Follow-up
Care of Acute and Chronic Heart Failure
Use of Mechanical Assist Devices
Donor Selection
Recipient Selection
Histologic Interpretation and Grading of
Myocardial Biopsies for Rejection
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).
Training and Experience

Description

Candidate Evaluation Process
Pre- and Post-Operative Hemodynamic Care
Post-Operative Immunosuppressive Therapy
Long-term Outpatient Follow-up
Care of Acute and Chronic Heart Failure
Use of Mechanical Assist Devices
Donor Selection
Recipient Selection
Histologic Interpretation and Grading of
Myocardial Biopsies for Rejection
Additional Information

Version date pending

Heart - 19

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
Version date pending

Heart - 20

Part 5: OPTN Staffing Report
HEART 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

Version date pending

Address

Heart - 21

Version date pending

Heart - 22

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

Version date pending

Address

Heart - 23

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

Version date pending

Address

Heart - 24

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

Version date pending

Address

Heart - 25

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

Heart - 26

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

Heart - 27

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: ____________________________________________
Extend lines on log as needed
Version date pending

Heart - 28

Date: ___________________

TABLE 4 Primary Physician Log (2) (Sample)
(List cases 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

Heart - 29

Specify Organ specific
or Multi-organ?