Organ Procurement and Transplantation Network Application Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form B9 B9	Form and Instruction	Modified	Available
Form B8 B8	Form and Instruction	Modified	Available
Form B7 B7	Form and Instruction	Modified	Available
Form B6 B6	Form and Instruction	Modified	Available
Form B5 B5	Form and Instruction	Modified	Available
Form B4 B4	Form and Instruction	Modified	Repair queued
Form B3 B3	Form and Instruction	Modified	Available
Form A2 A2	Form and Instruction	Modified	Available
Form B1 B1	Form and Instruction	Modified	Available
Form A1 A1	Form and Instruction	Modified	Available
Form C Application for Organ Procurement (OPO) Membership	Form and Instruction	Modified	Available
Form D Histocompatibility Laboratory Membership Application	Form and Instruction	Modified	Available
Form K Application for Individual Membership	Form and Instruction	Modified	Available
Form J Application for Business Membership	Form and Instruction	Modified	Available
Form I Application for Public Organization Membership	Form and Instruction	Modified	Available
Form H Application for Medical/Scientific Organization Membership	Form and Instruction	Modified	Available
Form G Application for Approval for Change in Key Personnel - OPO	Form and Instruction	Modified	Available
Form F Change in Key Personnel Application - Histocompatibility Laboratory	Form and Instruction	Modified	Available
Form E Personnel Change Application (Transplant Program)	Form and Instruction	Modified	Available
Summary of Changes.docx	Supplementary Document	Uploaded 2014-03-11	Available
Supporting Statement A.docx	Supporting Statement A	Uploaded 2014-04-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	B9
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	B8
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	B7
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	B6
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	B5
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	B4
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	B3
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	A2
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	B1
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	A1
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	Application for Organ Procurement (OPO) Membership
6410	Organ Procurement and Transplantation Network Application	Form and Instruction	Modified	Histocompatibility Laboratory Membership Application
183035	OPTN Appeal for Designation		Removed
183034	OPTN Designated Transplant Program Requirements		Removed
183033	OPTN Transplant to Prevent Organ Wastage		Removed
183032	OPTN Reasons for Refusal		Removed
183031	OPTN criteria reporting and disclosure		Removed
183030	OPTN Appeal for Membership		Removed
183029	OPTN Non-Institutional Application	Form and Instruction	Modified	Application for Individual Membership
183029	OPTN Non-Institutional Application	Form and Instruction	Modified	Application for Business Membership
183029	OPTN Non-Institutional Application	Form and Instruction	Modified	Application for Public Organization Membership
183029	OPTN Non-Institutional Application	Form and Instruction	Modified	Application for Medical/Scientific Organization Membership
183028	OPTN Personnel Change Application	Form and Instruction	Modified	Application for Approval for Change in Key Personnel - OPO
183028	OPTN Personnel Change Application	Form and Instruction	Modified	Change in Key Personnel Application - Histocompatibility Laboratory
183028	OPTN Personnel Change Application	Form and Instruction	Modified	Personnel Change Application (Transplant Program)

ICR Details

OMB Control No: 0915-0184	ICR Reference No: 201403-0915-002
Status: Historical Active	Previous ICR Reference No: 201102-0915-005
Agency/Subagency: HHS/HSA	Agency Tracking No: 21566
Title: Organ Procurement and Transplantation Network Application Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/16/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/17/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2017	36 Months From Approved	05/31/2014
Responses	1,547	0	36,868
Time Burden (Hours)	6,006	0	23,503
Cost Burden (Dollars)	0	0	0

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Abstract: The final rule of the Organ Procurement and Transplantation Network (OPTN) established the final policies governing the OPTN. This ICR contains application requirements outlined in the rule regarding application procedures and policies of the OPTN and membership, designation, and transplant program requirements. This submission contains burden associated with the final rule for application for membership in the OPTN and requirements for membership, including compliance with OPTN policies and bylaws.

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Authorizing Statute(s): US Code: 42 USC 273 Name of Law: National Organ Transplant Act
   US Code: 42 USC 1138 Name of Law: Hospital Protocols for Organ Procurement and Standards for Organ Procurement Agencies
   US Code: 42 USC 274 Name of Law: Organ Procurement and Transplantation Network
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 69695	11/20/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 11798	03/03/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
OPTN Appeal for Designation
OPTN Appeal for Membership
OPTN Designated Transplant Program Requirements
OPTN Non-Institutional Application	H, I, J, K	Application for Medical/Scientific Organization Membership ,   Application for Public Organization Membership ,   Application for Business Membership ,   Application for Individual Membership
OPTN Personnel Change Application	E, F, G	Personnel Change Application (Transplant Program) ,   Change in Key Personnel Application - Histocompatibility Laboratory ,   Application for Approval for Change in Key Personnel - OPO
OPTN Reasons for Refusal
OPTN Transplant to Prevent Organ Wastage
OPTN criteria reporting and disclosure
Organ Procurement and Transplantation Network Application	D, C, A1, B1, A2, B3, B4, B5, B6, B7, B8, B9	Histocompatibility Laboratory Membership Application ,   Application for Organ Procurement (OPO) Membership ,   A1 ,   B1 ,   A2 ,   B3 ,   B4 ,   B5 ,   B6 ,   B7 ,   B8 ,   B9

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,547	36,868	0	-36,404	1,083	0
Annual Time Burden (Hours)	6,006	23,503	0	-17,497	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: This renewal request is made with revisions to the expiring documents. The paperwork burden is decreasing. The application forms were revised to make them more respondent friendly. Specifically, the revised application is rewritten in plain language and asks only for information relevant to current membership requirements. It is estimated that the number of respondents will increase significantly. First, there will be more individual forms to fill out. However, each individual form will be shorter and easier to complete - therefore, the burden will not be increased. In addition, some membership application activities are being formalized with the development of two new data collection forms: o F Change in Histocompatibility Lab Director; and o G Change in OPO Key Personnel Although two new data forms have been developed, membership obligations have always required that this information be formally reported to the OPTN; as such, the new forms referenced above will not create a new burden for OPTN members.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/17/2014

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