G Application for Approval for Change in Key Personnel - O

APPLICATION FOR APPROVAL FOR CHANGE IN KEY PERSONNEL

ORGAN PROCUREMENT ORGANIZATION (OPO)

ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK (OPTN)

UNOS

700 North 4^th Street

Richmond, VA 23219

Main Phone: 804-782-4800

Name of OPO:
Address:
City, State, & Zip Code:
Contact Person/Title:
Phone Number:	Email:

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 this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, 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 10-29, 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. I understand that the intentional submission of false data to the OPTN may result in action by the Secretary of Health and Human Services, and/or civil or criminal penalties. By submitting this application to the OPTN, the applicant agrees: (i) to be bound by OPTN Obligations, 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:
Print Name:	Title:
Applicant #

Organ Procurement Organization

Change in Key Personnel

Check all applicable changes	Primary Personnel
	Administrative Director	Complete Part 1 below
	Medical Director	Complete Part 2 below

Part 1: Administrative Director

1. Identify the Administrative Director (Executive Director/CEO/President) who is responsible for organization operations, including effective organ recovery and placement. Attach curriculum vitae (CV)/resume.

Name	Mailing Address, Phone Number, & Email Address	Effective Date of appointment

2. If this appointment is for an interim period, when will a permanent director be hired? Describe recruitment plan.

[Insert detailed response here. Table will expand automatically]

Part 2: Medical Director

1. Identify the Medical Director who is ultimately responsible for the medical and clinical activities of the OPO. Attach curriculum vitae (CV).

Name	Mailing Address, Phone Number, & Email Address	Effective Date of appointment

Expand rows as needed

2. Is this appointment for an interim period, a specific term, or not term limited?

If the appointment is interim or for a specific term, indicate term beginning and end dates (mm/dd/yy) and explain the recruitment plan, including timeline.

[Insert detailed response here. Table will expand automatically]

3. Medical Directors must be licensed in at least one of the states in the OPO’s DSA. Indicate the states in which the medical director is licensed.

[Insert detailed response here. Table will expand automatically]

4. Is more than one person named as a medical director? If yes, provide the following information for each additional director.

Name	Mailing Address, Phone Number, & Email Address	Term of appointment MM/DD/YY	State(s) where licensed