Department of Health and Human Services OMB No. 0915-0184
Health Resources and Services Administration Expiration Date: _____
APPLICATION FOR INSTITUTIONAL MEMBERSHIP
AS A CLINICAL TRANSPLANT HOSPITAL
IN THE ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK (OPTN)
United Network for Organ Sharing (UNOS)
700 North 4th Street
Richmond, VA 23219
Main Phone: 804-782-4800
Name of Hospital:
Hospital Address:
City, State, & Zip Code:
Contact Person and Title:
Phone: ( )
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 45 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 (OPTN) rules and requirements, 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:
Applicant Code: Print Name:
Print Title:
Instructions
1. A Clinical Transplant Hospital applicant must complete the Parts 1-6 that follow these Instructions, including the organ specific section for each type of transplant program for which it is applying. The Criteria for Institutional Membership are found in the Bylaws.
Transplant programs are:
A. Kidney (including Living Donor Kidney) E. Pancreas
B. Heart F. Lung
C. Heart/Lung H. Islet Cell
D. Liver (including Living Donor Liver)
Additionally, the Organ Procurement and Histocompatibility Sections (Parts 5 and 6) will need to be completed.
2. 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 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. The Criteria for Institutional Membership are found in the Bylaws which can be accessed on the OPTN website at http://optn.transplant.hrsa.gov/.
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 requests for supplemental information constitutes grounds for denial or suspension of OPTN membership. (Authorized representatives include hospital CEO or President. Individuals whose credentials are being submitted should not sign the application.)
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 in full and do not use both sides of the page. "See C.V." or “See Logs” is not an acceptable answer.
6. Supporting documentation, such as C.V.’s, letters of support, letters of commitment, and patient logs, should be included as requested to document compliance with the requirements. Documentation may be blinded in such a way as to protect patient confidentiality.
7. 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.
8. Each set (original and copy) should be loose bound with tabs. Original and copy should be organized in the following sequence:
1) Signed Cover Page
2) General Section
3) Organ Specific Application(s)
4) Signed Program Coverage Plan(s) – one must be submitted for each organ-specific application
5) OPO Section
6) Lab Section
7) Documentation of Medicare/Medicaid certification (if applicable)
8) Letters from Hospital Credentialing Committee
9) Letters of Commitment
10) Letters of Reference
11) 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 as shown in the sample logs. Please use a separate log for each institution.
12) CVs Abbreviated CVs that do not include publications and presentations are preferred.
13) Cumulative Recipient log (Islet only)
14) Allocation Report (Islet only)
9. Return the original and one (1) complete paper copy of all application materials to UNOS at the address listed below.
Express Mail: US Mail:
UNOS UNOS
700 North 4th Street PO Box 2484
Richmond, VA 23219 Richmond, VA 23218
Main Phone: (804) 782-4800
11/29/2010 version
| File Type | application/msword |
| File Modified | 2011-02-03 |
| File Created | 2011-02-03 |