Form K K_Individual_Clean_HRSA

Department of Health and Human Services

Health Resources and Services Administration

APPLICATION FOR INDIVIDUAL MEMBERSHIP IN THE

ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK (OPTN)

UNOS

700 North 4^th Street

Richmond, VA 23219

Main Phone: (804) 782-4800

Name of Applicant:
Address:
City, State, & Zip Code:
Contact Person:
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 14N-39, 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 the Department 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:
OPTN Member Code:

Answer at least one of questions 1-6.

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(s) (or board) and the term(s) of service.

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2. Are you or a family member a transplant candidate, transplant recipient, living donor, or tissue donor? (indicate all that apply)

	Self	Family	Organ
Transplant Candidate
Transplant Recipient
Living Donor
Tissue Donor

3. Are you presently employed by or are you an independent contractor with an organ procurement organization (OPO), transplant hospital, or histocompatibility laboratory?

Yes:

No:

If “yes”, explain below.

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4. Were you formerly employed by or were you formerly an independent contractor with an OPO, transplant hospital, or histocompatibility laboratory?

Yes:

No:

If “yes”, describe and explain how you have continued to demonstrate an active interest and involvement in organ donation or transplantation.

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5. Were you formerly employed by a Federal or State government agency involved in organ donation and transplantation?

Yes:

No:

If “yes”, explain how you have continued to demonstrate an active interest and involvement in organ donation or transplantation.

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6. Do you have an active interest and involvement in organ donation or transplantation?

Yes:

No:

If you are utilizing this option to request membership, you must provide at least three letters of recommendation for membership from three other OPTN individual members. Attach these letters of support.

7. Attach a copy of your resume or curriculum vitae.

8. Explain your reason for wanting to be an Individual Member of the OPTN.

(Confine your statement to approximately one page)

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Version pending Individual - 2