Information Collection

Organ Procurement and Transplantation Network Application

IC 6410 under ICR 201403-0915-002 · OMB 0915-0184.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0184 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form D Organ Procurement and Transplantation Network Application	Form and Instruction
D Histocompatibility Laboratory Membership Application D_HistoLab.doc	Form and Instruction
C Application for Organ Procurement (OPO) Membership C_OPO.doc	Form and Instruction
A1 A1 A1_NewTransplantHospital_Cover.doc	Form and Instruction
B1 B1 B1_NewTransplantProgram_Cover.doc	Form and Instruction
A2 A2 A2_NewTransplantHospital_General.doc	Form and Instruction
B3 B3 B3_Kidney_LDKidney.doc	Form and Instruction
B4 B4 B4_Liver_LDLiver.doc	Form and Instruction
B5 B5 B5_Pancreas.doc	Form and Instruction
B6 B6 B6_Heart.doc	Form and Instruction
B7 B7 B7_Lung.doc	Form and Instruction
B8 B8 B8_PancreasIslet.doc	Form and Instruction
B9 B9 B9_LivingDonorRecoveries.doc	Form and Instruction

IC Title:

Organ Procurement and Transplantation Network Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 121

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	D	Histocompatibility Laboratory Membership Application	D_HistoLab.doc	Yes	Yes	Fillable Printable
Form and Instruction	C	Application for Organ Procurement (OPO) Membership	C_OPO.doc	Yes	Yes	Fillable Printable
Form and Instruction	A1	A1	A1_NewTransplantHospital_Cover.doc	Yes	Yes	Fillable Printable
Form and Instruction	B1	B1	B1_NewTransplantProgram_Cover.doc	Yes	Yes	Fillable Printable
Form and Instruction	A2	A2	A2_NewTransplantHospital_General.doc	Yes	Yes	Fillable Printable
Form and Instruction	B3	B3	B3_Kidney_LDKidney.doc	Yes	Yes	Fillable Printable
Form and Instruction	B4	B4	B4_Liver_LDLiver.doc	Yes	Yes	Fillable Printable
Form and Instruction	B5	B5	B5_Pancreas.doc	Yes	Yes	Fillable Printable
Form and Instruction	B6	B6	B6_Heart.doc	Yes	Yes	Fillable Printable
Form and Instruction	B7	B7	B7_Lung.doc	Yes	Yes	Fillable Printable
Form and Instruction	B8	B8	B8_PancreasIslet.doc	Yes	Yes	Fillable Printable
Form and Instruction	B9	B9	B9_LivingDonorRecoveries.doc	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 376

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	744	0	624	120
Annual IC Time Burden (Hours)	2,908	1,108	0	1,800
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.