Information Collection

OPTN Membership Application for Pancreas Transplant Programs

IC 226683 under ICR 202006-0915-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 5 OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction
5 Membership_Pancreas Form.docx Membership_Pancreas Form.docx	Form and Instruction
5B Membership_SurgeonOrPhysicianLog Form.docx Membership_SurgeonOrPhysicianLog Form.docx	Form and Instruction

IC Title:

OPTN Membership Application for Pancreas Transplant Programs

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5	Membership_Pancreas Form.docx	Membership_Pancreas Form.docx		Yes	Yes	Fillable Fileable
Form and Instruction	5B	Membership_SurgeonOrPhysicianLog Form.docx	Membership_SurgeonOrPhysicianLog Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	240	120	120
Annual IC Time Burden (Hours)	720	240	480
Annual IC Cost Burden (Dollars)	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.