Information Collection Request

Organ Procurement and Transplantation Network Application Form

ICR 202106-0915-002 · OMB 0915-0184 · Received in OIRA

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 17 OPTN Individual Membership Application Form and Instruction Unchanged Repair queued
Form 16 OPTN Business Membership Application Form and Instruction Unchanged Repair queued
Form 15 OPTN Public Organization Membership Application Form and Instruction Unchanged Repair queued
Form 14 OPTN Medical Scientific Membership Application Form and Instruction Unchanged Repair queued
Form 13 OPTN Representative Form Form and Instruction Unchanged Repair queued
Form 12 OPTN Membership Application for Histocompatibility Labs Form and Instruction Unchanged Missing upstream
Form 11 OPTN Membership Application for OPOs Form and Instruction Unchanged Repair queued
Form 10 OPTN Membership Application for Intestine Transplant Programs Form and Instruction Unchanged Repair queued
Form 2 OPTN Certificate of Assessment and Program Coverage Plan Membership Application Form and Instruction Unchanged Available
Form 9 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application Form and Instruction Unchanged Missing upstream
Form 8 OPTN Membership Application Islet Transplant Program Form and Instruction Unchanged Repair queued
Form 7 OPTN Membership Application for Lung Transplant Program Form and Instruction Unchanged Repair queued
Form 6 OPTN Membership Application for Heart Transplant Program Form and Instruction Unchanged Missing upstream
Form 5 OPTN Membership Application for Pancreas Transplant Programs Form and Instruction Unchanged Repair queued
Form 4 OPTN Membership Application for Liver Transplant Progrms Form and Instruction Unchanged Repair queued
Form 3 OPTN Membership Application for Kidney Transplant Programs Form and Instruction Unchanged Repair queued
Form 1 OPTN Membership Application for Transplant Hospitals Form and Instruction Unchanged Repair queued
05272021 - OPTN Membership Application for Heart Transplant Programs - REDLINE.docx Supplementary Document Uploaded 2021-06-02 Repair queued
05272021 - OPTN Membership Application for Heart Transplant Programs - CLEAN.docx Supplementary Document Uploaded 2021-06-02 Repair queued
FINAL Change Memo - OPTN Membership Forms - 0915-0184.docx Justification for No Material/Nonsubstantive Change Uploaded 2021-06-02 Repair queued
FINAL Supporting Statement - 0915-0184.docx Supporting Statement A Uploaded 2020-06-26 Repair queued
60-Day OPTN FRN OMB No. 0915-0184.Published.pdf Supplementary Document Uploaded 2020-06-26 Repair queued
Names_Crosswalk.xlsx Supplementary Document Uploaded 2020-06-26 Repair queued
05.19.2020 Summary of Changes - OPTN 0915-0184.docx Supplementary Document Uploaded 2020-06-26 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
226701 OPTN Individual Membership Application Form and Instruction Unchanged
226700 OPTN Business Membership Application Form and Instruction Unchanged
226699 OPTN Public Organization Membership Application Form and Instruction Unchanged
226698 OPTN Medical Scientific Membership Application Form and Instruction Unchanged
226695 OPTN Representative Form Form and Instruction Unchanged
226694 OPTN Membership Application for Histocompatibility Labs Form and Instruction Unchanged
226693 OPTN Membership Application for OPOs Form and Instruction Unchanged
226692 OPTN Membership Application for Intestine Transplant Programs Form and Instruction Unchanged
226689 OPTN Certificate of Assessment and Program Coverage Plan Membership Application Form and Instruction Unchanged
226687 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application Form and Instruction Unchanged
226686 OPTN Membership Application Islet Transplant Program Form and Instruction Unchanged
226685 OPTN Membership Application for Lung Transplant Program Form and Instruction Unchanged
226684 OPTN Membership Application for Heart Transplant Program Form and Instruction Unchanged
226683 OPTN Membership Application for Pancreas Transplant Programs Form and Instruction Unchanged
226682 OPTN Membership Application for Liver Transplant Progrms Form and Instruction Unchanged
226681 OPTN Membership Application for Kidney Transplant Programs Form and Instruction Unchanged
226680 OPTN Membership Application for Transplant Hospitals Form and Instruction Unchanged

ICR Details

Reginfo record details
table that charts list comparision
  Requested Previously Approved
08/31/2023 08/31/2023
1,661 1,661
4,755 4,755
0 0





Reginfo record details
17
table that charts list of burden
IC Title Form No. Form Name
OPTN Business Membership Application 16 Membership_Business Form.docx
OPTN Certificate of Assessment and Program Coverage Plan Membership Application 2 Membership_CertificateAssessment_ProgramCoverage Form.docx
OPTN Individual Membership Application 17 Membership_Individual Form.docx
OPTN Medical Scientific Membership Application 14 Membership_MedicalScientific Form.docx
OPTN Membership Application Islet Transplant Program 8, 8B Membership_Pancreas Islet Form.docx ,   Membership_SurgeonOrPhysicianLog Form.docx
OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application 9B, 9 Membership_VCA Form.docx ,   Membership_SurgeonOrPhysicianLog Form.docx
OPTN Membership Application for Heart Transplant Program 6, 6B Membership_Heart Form.docx ,   Membership_SurgeonOrPhysicianLog Form.docx
OPTN Membership Application for Histocompatibility Labs 12 Membership_HistoLab Form.docx
OPTN Membership Application for Intestine Transplant Programs 10, 10B Membership_Intestine Form.docx ,   Membership_SurgeonOrPhysicianLog Form.docx
OPTN Membership Application for Kidney Transplant Programs 3 , 3B Membership_Kidney_LDKidney Form.docx ,   Membership_SurgeonOrPhysicianLog Form.docx
OPTN Membership Application for Liver Transplant Progrms 4, 4B Membership_Liver_LDLiver Form.docx ,   Membership_SurgeonOrPhysicianLog Form.docx
OPTN Membership Application for Lung Transplant Program 7B, 7 Membership_Lung Form.docx ,   Membership_SurgeonOrPhysicianLog Form.docx
OPTN Membership Application for OPOs 11 Membership_OPO Form.docx
OPTN Membership Application for Pancreas Transplant Programs 5B, 5 Membership_Pancreas Form.docx ,   Membership_SurgeonOrPhysicianLog Form.docx
OPTN Membership Application for Transplant Hospitals 1 Membership_Transplant Hospital_General Form.docx
OPTN Public Organization Membership Application 15 Membership_PublicOrg Form.docx
OPTN Representative Form 13 Membership_Representative Form.docx

table that charts list of burden
  Total Request 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 1,661 1,661 0 0 0 0
Annual Time Burden (Hours) 4,755 4,755 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No