Department of Health and Human Services OMB No. 0915-0184
Health Resources and Services Administration Expiration Date: _____
APPLICATION FOR MEMBERSHIP AS A
ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK (OPTN)
UNOS
700 North 4th Street
Main Phone: (804) 782-4800
Name of Organization ________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________
City, State, & Zip Code: _________________________________________________________________
Contact Person: _______________________________________________________________
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.
Signature: _____________________________________________ Date: _______________________
Print Name: ______________________________________________ Title: ______________________
Applicant Code: _____________
1. The Criteria for Public Organization Membership are found in the OPTN Charter, Article IV - Membership.
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 requests for supplemental information, constitute grounds for denial or suspension of OPTN membership.
4. Application responses must be typed and complete.
- Do not submit two-sided pages.
- Attach additional pages as necessary and reference the question and page number on each attachment.
- An electronic version (MS Word) of this application is available upon request.
5. Return the original application and one (1) complete copy. Please also return a copy of the application that has been scanned to a CD in PDF format. Label the CD with the Organization name, contact name, and date, and include an electronic table of contents.
Express Mail: US Mail:
UNOS UNOS
Administrator, Membership Services Administrator, Membership Services
700 North 4th Street PO Box 2484
Richmond, VA 23219 Richmond, VA 23218
Main Phone: (804) 782-4800
1. Provide the following documents:
a) A current roster of the organization/institution's board of directors and officers.
b) A copy of the organization/institution's Articles of Incorporation and Bylaws.
c) A copy of the organization/institution's last annual report or annual financial report.
Answer either question 2 (a) and (b); or 2 (a) and (c); or question 3 below:
2. A Public Organization Member shall be “an established, non-profit organization or institution with at least one year of operating history that has an interest in the fields of organ donation or transplantation, defined as” item b or c below:
a) Attach a copy of the organization/institution's IRS non-profit status letter.
b) Describe how this organization/institution meets the requirement for being “An organization or institution that engages in organ donation activities or represents or provides direct support or services to transplant recipients, transplant candidates, or their families.” Alternatively, provide the documentation as described in question 2c (below.)
c) An organization or institution that is supported by letters of recommendation for OPTN membership from at least three other OPTN member organizations or institutions, each of which meets the criteria for OPTN Institutional Membership listed in Article IV.
3. A Public Organization Member shall be “A hospital with at least one year of operating history that participates in the Medicare or Medicaid programs and has an interest in the fields of organ donation or transplantation, defined by the referral of at least one potential organ or tissue donor per year for donation.”
Provide documentation that demonstrates that the Hospital meets the above criteria.
Public
Organization -
| File Type | application/msword |
| File Modified | 2011-02-03 |
| File Created | 2011-02-03 |