Form 0

Department of Health and Human Services
Health Resources and Services Administration

OMB No. pending
Expiration Date: pending

PERSONNEL CHANGE APPLICATION
CLINICAL TRANSPLANT PROGRAM
ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK (OPTN)
UNOS

700 North 4th Street
Richmond, VA 23219
Main Phone: 804-782-4800
Name of Hospital:

__________________________________________________________________

Address:

__________________________________________________________________
__________________________________________________________________

City, State, &Zip Code: __________________________________________________________________
Application 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
10 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 agrees: (i) to be bound by the Organ Procurement and Transplantation
Network's rules and regulations, 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:

______________________

Center Code: __________________

Signature: _____________________________________
Print Name: ____________________________________
Title: ___________________________________________

Version date pending

INSTRUCTIONS FOR THE COMPLETION OF PERSONNEL CHANGE APPLICATION
1.

A duly authorized representative of the transplant center must review the answers and attachments to the
change forms, perform sufficient investigation to determine accuracy and completeness, and sign and date the
Certification on the cover page of the form. Failure to furnish accurate and complete information in connection
with the form and subsequent site visits and requests for supplemental information, constitutes grounds for
denial or suspension of OPTN membership. (Authorized representatives include hospital CEO/President,
OPTN Representative, and Program Directors. Individuals whose credentials are being submitted should
not sign the application.)

2.

Application responses must be typed and complete. Do not omit pages that were not used. Electronic versions
(Microsoft Word or Adobe PDF) of this application are available upon request.

3.

Do not submit two-sided pages.

4.

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

5.

Answer all questions that pertain to the primary surgeon and/or primary physician change in full. "See
C.V." and “see logs” are not acceptable answers. You only to need to complete the pages that are
applicable to the change(s) that have taken place except for Part 3A, Part 4, and Part 5,which should be
answered for all applicants (Part 3A, Part 5 and Part 6 for liver/living donor liver and kidney
applicants).

6.

CV's should be included for all primary and new personnel listed. Abbreviated CV’s that do not include
publications and presentations are preferred.

7.

Each set (original and copy) should be loose bound with tabs. Originals and copy should be organized in the
following sequence:
a) Application form (including signed certification page) and staffing survey.
b) Documentation of Medicare/Medicaid certification of this program (as applicable)
c) Letters from Hospital Credentialing Committee
d) Letters of Commitment
e) Letters of Reference
f)
Logs of transplant and procurement procedures (and living donor hepatectomies/nephrectomies as
applicable) for the primary surgeon(s) and patient logs for the primary physician.
Title each log with surgeon/physician name, date range, and hospital where the experience occurred.
Please use a separate log for each institution.
g) CV’s (individual CV’s must be stapled together in the original and hardcopy)
h) Cumulative Recipient log (Islet only)
i9) Allocation Report (Islet only)

8.

Supporting documentation such as letters of support, letters of commitment, and patient logs must be included
as requested to document compliance with OPTN requirements. Documentation may be blinded in such a way
as to protect patient confidentiality. Checklists are provided throughout the application to help applicants
compile the documentation that is required. Each item in the checklist is cross referenced to the application
questions.

9.

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.

10

The Criteria for Institutional Membership are found in the Bylaws which can be accessed on the OPTN website
at www.optn.org.

Version date pending

11.

Return the original and one (1) complete paper copy of all application materials. Please also return a
copy of the application that has been scanned to a CD in PDF format. Label the CD with the Hospital
name, contact name, and date and include an electronic table of contents.

12.

Completed packets should be shipped as listed below:
Membership Services
UNOS
700 N. 4th Street
Richmond, VA 23219
Main Phone: 804-782-4800

Version date pending