Information Collection Request

Organ Procurement and Transplantation Network Application Form

ICR 201802-0915-002 · OMB 0915-0184 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form K K Individual Member Application Form and Instruction Unchanged Available
Form j J Business Member Application Form and Instruction Unchanged Available
Form I I Public Org Application Form and Instruction Unchanged Available
Form H H Medical Scientific Org Application Form and Instruction Unchanged Available
Form G G Change in OPO Key Personnel Form and Instruction Unchanged Available
Form F F Change in Histocompatibility Lab Director Form and Instruction Unchanged Available
Form F E Personnel Change Cover Application Form and Instruction Unchanged Repair queued
Form D D Histocompatibility Lab Application Form and Instruction Unchanged Repair queued
Form C C OPO New Application Form and Instruction Unchanged Repair queued
Form B17 B Intestine Designated Program Application Form and Instruction Unchanged Available
Form B16 a B VCA Other Designated Program Application Form and Instruction Unchanged Available
Form B12 B VCA Abdominal Wall Designated Program Application Form and Instruction Unchanged Available
Form B11 B VCA Upper Limb Designated Program Application Form and Instruction Unchanged Available
Form B10 B VCA Head and Neck Designated Program Application Form and Instruction Unchanged Available
Form B9 B Living Donor (LD) Recovery Program Application Form and Instruction Unchanged Available
Form B8 B Islet (PI) Designated Program Application Form and Instruction Unchanged Repair queued
Form B7 B Lung (LU) Designated Program Application Form and Instruction Unchanged Available
Form B6 B Heart (HR) Designated Program Application Form and Instruction Unchanged Available
Form B5 B Pancreas (PA) Designated Program Application Form and Instruction Unchanged Available
Form B4 B Liver (LI) Designated Program Application Form and Instruction Unchanged Available
Form B3 B Kidney (KI) Designated Program Application Form and Instruction Unchanged Available
Form A1 A New Transplant Hospital Program Application - General Form and Instruction Unchanged Repair queued
20180209 Attachment A OPTN B10 Intestine Form.doc Supplementary Document Uploaded 2018-02-27 Available
20180216 OPTN Membership Forms Change Memo CLEAN.docx Justification for No Material/Nonsubstantive Change Uploaded 2018-02-27 Available
OMB 0915-0184 Supporting Statement A rev 05012017.docx Supporting Statement A Uploaded 2017-05-03 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
226701 K Individual Member Application Form and Instruction Unchanged
226700 J Business Member Application Form and Instruction Unchanged
226699 I Public Org Application Form and Instruction Unchanged
226698 H Medical Scientific Org Application Form and Instruction Unchanged
226697 G Change in OPO Key Personnel Form and Instruction Unchanged
226696 F Change in Histocompatibility Lab Director Form and Instruction Unchanged
226695 E Personnel Change Cover Application Form and Instruction Unchanged
226694 D Histocompatibility Lab Application Form and Instruction Unchanged
226693 C OPO New Application Form and Instruction Unchanged
226692 B Intestine Designated Program Application Form and Instruction Unchanged
226691 B VCA Other Designated Program Application Form and Instruction Unchanged
226690 B VCA Abdominal Wall Designated Program Application Form and Instruction Unchanged
226689 B VCA Upper Limb Designated Program Application Form and Instruction Unchanged
226688 B VCA Head and Neck Designated Program Application Form and Instruction Unchanged
226687 B Living Donor (LD) Recovery Program Application Form and Instruction Unchanged
226686 B Islet (PI) Designated Program Application Form and Instruction Unchanged
226685 B Lung (LU) Designated Program Application Form and Instruction Unchanged
226684 B Heart (HR) Designated Program Application Form and Instruction Unchanged
226683 B Pancreas (PA) Designated Program Application Form and Instruction Unchanged
226682 B Liver (LI) Designated Program Application Form and Instruction Unchanged
226681 B Kidney (KI) Designated Program Application Form and Instruction Unchanged
226680 A New Transplant Hospital Program Application - General Form and Instruction Unchanged

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
07/31/2020 07/31/2020 07/31/2020
1,868 0 1,868
7,020 0 7,020
0 0 0





Reginfo record details
22
table that charts list of burden
IC Title Form No. Form Name
B Heart (HR) Designated Program Application B6 B6_HR Heart_Clean.doc
B Living Donor (LD) Recovery Program Application B9 B9_LD NewLivingDonorRecoveries_Clean.doc
B VCA Upper Limb Designated Program Application B11 B VCA_Upper Limb_Updated.doc
B VCA Abdominal Wall Designated Program Application B12, B13, B14, B15 B12 VCA_AW_Kidney_Updated.doc ,   B13 VCA_AW_Liver_Updated.doc ,   B14 _VCA_AW_Pancreas_Updated.doc ,   B15 VCA_AW_Intestine_Updated.doc
B VCA Other Designated Program Application B16 c, B16 a, B16 b B16 a VCA_Other_Updated.doc ,   B16 b VCA_Other_NewTransplantProgram_Cover_HRSA.doc_.doc ,   B16 c VCA_Other_PersonnelChange_Cover_HRSA.doc_.doc
B Intestine Designated Program Application B17 B17 Intestine_HRSA.doc
D Histocompatibility Lab Application D D_HistoLab_New_Clean_HRSA.doc
I Public Org Application I I_PublicOrg_Clean_HRSA.doc
C OPO New Application C C_OPO_New_final_Clean_HRSA.doc
E Personnel Change Cover Application F F_HistoLab_PersonnelChange_Clean_HRSA.doc
F Change in Histocompatibility Lab Director F F_HistoLab_PersonnelChange_Clean_HRSA.doc
G Change in OPO Key Personnel G G_OPO_DirectorChange_final_clean_HRSA.doc
H Medical Scientific Org Application H H_MedicalScientific_Clean_HRSA.doc
J Business Member Application j J_Business_Clean_HRSA.doc
K Individual Member Application K K_Individual_Clean_HRSA.doc
B Kidney (KI) Designated Program Application B3 B3_Kidney_LDKidney_Clean.doc
B Liver (LI) Designated Program Application B4 B4_L1 Liver_LDLiver_Clean.doc
B Pancreas (PA) Designated Program Application B5 B5_PA Pancreas_Clean.doc
A New Transplant Hospital Program Application - General B2, A2, B1, A1 A1_NewTransplantHospital_Cover_HRSA.doc ,   A2_NewTransplant_General_Clean.doc ,   B1_NewTransplantProgram_Cover_Clean_HRSA.doc ,   B2 VCA_NewTransplantProgram_Cover_HRSA.doc
B Lung (LU) Designated Program Application B7 B7_LU Lung_Clean.doc
B Islet (PI) Designated Program Application B8 B8_PI PancreasIslet_Clean.doc
B VCA Head and Neck Designated Program Application B10 B VCA_Head and Neck_Updated.doc

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 1,868 1,868 0 0 0 0
Annual Time Burden (Hours) 7,020 7,020 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No