Department of Health and Human Services OMB No. 0915-0184
Health Resources and Services Administration Expiration Date: _______
ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK (OPTN)
UNOS
700 North 4th Street
Main Phone: (804) 782-4800
Name of Applicant ________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________
City, State, & Zip Code: _________________________________________________________________
Phone Number: (______)____________________
Email Address: __________________________________
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 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 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 Individual Membership are found in the OPTN Charter, Article IV - Membership.
2. By submitting this application to the OPTN, the applicant acknowledges that they have received and read the current Articles of Incorporation 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. 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 to:
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
Name of Applicant: _____________________________________________________________
Individual Members. An Individual Member shall be a person with an interest and/or expertise in the fields of organ donation or transplantation.
Part 1
Please answer at least one of the Questions 1-5
1. Do you presently serve or have you formerly served on the OPTN Board of Directors, or an OPTN Committee. ____ Yes ____ No.
If “Yes,” indicate the name of the specific Committee (or Board) and the term(s) of service.
2. Are you or a family member -
A transplant candidate ? Self ___ Family ____ Organ ____
Transplant recipient? Self ___ Family ____ Organ ____
Organ or tissue donor? Self ___ Family ____
(check all that apply)
3. Are you presently employed by or are independent contractors with OPOs, Transplant Hospitals, or Histocompatibility Laboratories? ____ Yes ____ No.
If Yes, please explain.
4. Were you formerly employed by or were formerly an independent contractor with OPOs, Transplant Hospitals, or Histocompatibility Laboratories? ____ Yes ___ No
Were you formerly employed by Federal or State government agencies involved in the field of organ donation and transplantation? _____ Yes _____ No
If you answered “yes” to either one or both of these questions, explain how you have continued to demonstrate an active interest in and involvement with the fields of organ donation or transplantation.
5. Do you have an active interest in and involvement with the fields of organ donation or transplantation?
If so, this must be demonstrated by letters of recommendation for OPTN membership from at least three persons, each of who meets the criteria for Individual Membership listed in Article IV in the Charter. Please attach these letters of support.
Individual -2
6. Attach a copy of your resume or curriculum vitae.
(Please confine your statement to one page)
Individual - 3
12/01/2010 version
| File Type | application/msword |
| File Modified | 2011-02-03 |
| File Created | 2011-02-03 |