OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application

Organ Procurement and Transplantation Network Application Form

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 9 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application Form and Instruction
9 Membership_VCA Form.docx Membership_VCA Form.docx Form and Instruction
9B Membership_SurgeonOrPhysicianLog Form.docx Membership_SurgeonOrPhysicianLog Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program 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:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	9	Membership_VCA Form.docx	Membership_VCA Form.docx		Yes	Yes	Fillable Fileable
Form and Instruction	9B	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: 53	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	106	22	84
Annual IC Time Burden (Hours)	212	-40	252
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.