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Department of Health and Human Services
Health Resources and Services Administration

OMB No. pending
Expiration Date: pending

APPLICATION FOR APPROVAL FOR INSTITUTIONAL MEMBERSHIP
AS A HOSPITAL BASED TISSUE TYPING LABORATORY IN AN EXISTING MEMBER CENTER
IN THE ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK (OPTN)
UNOS
700 North 4th Street
Richmond, VA 23219
Main Phone: 804-782-4800

Name of Member Hospital: _________________________________________________________
Name Laboratory:___________________________________________________________________
Address:

___________________________________________________________________

City, State, & Zip Code:

___________________________________________________________________

Contact Person and Title: ___________________________________________________________________
Phone Number:

(_______)_____________________________

PUBLIC BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control
number for this project is 0915-0184. Public reporting burden for the applicant for this collection of information is
estimated to average 40 hours per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33,
Rockville, Maryland 20857.
CERTIFICATION
The undersigned, a duly authorized representative of the applicant, does hereby certify that the answers and
attachments to this application are true, correct and complete, to the best of his or her knowledge after investigation.
By submitting this application to the OPTN, the applicant acknowledges that its duly authorized representatives
have received and read the current Charter, Bylaws, and Policies of OPTN and the applicant agrees: (i) to be bound
by the terms thereof, including amendments thereto, if the applicant is granted membership and (ii) to be bound by
the terms, thereof, including amendments thereto, in all matters relating to consideration of the application without
regard to whether or not the applicant is granted membership.

Date: _____________________

Signature: _____________________________________________
Print Name: ___________________________________________

Applicant # ______________

Version date pending

Print Title: ___________________________________________

Histocompatibility Laboratory

1.

A histocompatibility laboratory must complete this application for institutional membership. The Criteria
for Institutional Membership are found in the Bylaws, which can be accessed on the OPTN website at
www.optn.org.

2.

By submitting this application to the OPTN, the applicant acknowledges that its duly authorized
representatives have received and read the current Charter and Bylaws of the OPTN and the applicant
agrees: (i) to be bound by the terms thereof, including amendments thereto, if the applicant is granted
membership and (ii) to be bound by the terms thereof, including amendments thereto, in all matters relating
to consideration of the application without regard to whether or not the applicant is granted membership.

3.

A duly authorized representative of the applicant must review the answers and attachments to the
Application, perform sufficient investigation to determine accuracy and completeness, and sign and date
the Certification on the cover page of the Application. Failure to furnish accurate and complete
information in connection with the Application and subsequent site visits and requests for supplemental
information constitutes grounds for denial or suspension of OPTN membership.

4.

Additional Instructions are provided under Part 5, Section C(1).

5.

Attach additional pages as necessary and reference the question and page number on each attachment.
Expand rows in tables as needed to completely answer the questions.

6.

Answer all questions in full and do not use both sides of the page. "See C.V." is not an acceptable answer.

7.

Supporting documentation such as C.V.’s, should be included as requested to document compliance with the
requirements. Documentation may be blinded in such a way as to protect patient confidentiality.

8.

Application responses must be typed and complete. Do not omit pages that were not used. The
Membership and Professional Standards Committee (MPSC) may not accept for review applications that
are not appropriately completed and that are missing the supporting documents for the proposed primary
individual(s). Applications determined to be incomplete may be returned to the institution.

9.

Return the original and one (1) complete paper copy of all application materials to UNOS at the address
listed below. Please also return a copy of the application that has been scanned to a CD in PDF format.
Label the CD with the Hospital & Lab name, contact name, date ,and include an electronic table of
contents.
Administrator, Member Services
UNOS
700 North 4th Street
Richmond, VA 23219
Main Phone: 804-782-4800