4B Membership_SurgeonOrPhysicianLog Form

Organ Procurement and Transplantation Network Application Form

Membership_SurgeonOrPhysicianLog Form

OPTN Membership Application for Liver Transplant Progrms

OMB: 0915-0184

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Department of Health and Human Services Health Resources and Services Administration

OMB No. 0915-0184

Expiration Date: XX/XX/2023





OPTN Membership Application - Surgeon or Physician Log

Surgeon

Text Field











Organ

Drop Down

All Organs










Pathway

Drop Down

All Pathways










Hospital

Drop Down

All Existing TX

Hospitals










Time Frame at Hospital

Start

End











Calendar

Calendar












Signature Required For:

Drop Down Residency FX

IN

VCA PI



Name

Text Field



Title

Text Field












All Organs Included in OPTN Bylaws


Kidney and LDK


Intestine


Lung


Vascular Composite Allograft


Pancreas Islet


Components that perform transplants in recipients less than 18 years old




Type of Procedure



Date of : Procedure/

Eval Date/Date of Care Provided



Patient Identifier TX: MR#

Pro: Donor ID




Role of Surgeon




KI & LDK: Type of Donor




IN: Did the recovery also include the LI?



LU: Was this a combined H/L Transplant?



VCA: Other - Microvascular Procedure



VCA: Other - Name of Team Member with Microvascular Experience



PI: Was the Procedure Allogenic or Autologous?




Date of Birth




Weight at Time of Transplant if <25 kg



Drop Down (see all below)



Calendar



Text Field

Drop Down Primary

Co-Surgeon First Assistant


Drop Down Deceased Living



Check if applicable



Check if applicable



Text Field



Text Field



Drop down



Calendar

Calc: DOT-DOB=Age



Text Field


Transplant (can be multi organ if organ applying for is included) (Transplant must be in the VCA Type applying for)












Procurement (must include organ applying for)












LDK: Open Nephrectomy












LDK: Lap Nephrectomy












LDL: Major Liver Resection












LDL: Major Liver Resection-Live Donor












VCA: Multi-Organ Procurement Observation












VCA: Upper Limb - Pre-Op Eval of Potential TX

Pts












VCA: Upper Limb - Post-Op Follow up of a

Recipient for 1 Year












VCA: Upper Limb - Bone












VCA: Upper Limb - Nerve












VCA: Upper Limb - Tendon












VCA: Upper Limb - Skin or Wound Problems












VCA: Upper Limb - Contracture or Joint Stiffness












VCA: Upper Limb - Tumor












VCA: Upper Limb - Microsurgical Procedures

Free Flaps












VCA: Upper Limb - Non-surgical Management












VCA: Upper Limb - Replantation or Transplant












VCA: Head & Neck - Pre-Op Eval of Potential TX

Pts












VCA: Head & Neck - Post-Op Follow up of a

Recipient for 1 Year












VCA: Head & Neck - Facial trauma with bone

fixation












VCA: Head & Neck - Head or neck free tissue

reconstruction












VCA: Other - Pre-Op Eval of Potential VCA TX Pts












VCA: Other - Microvascular Experience












PI: Management & Care of Islet Transplant

Patients












PI: Management & Care - Selecting Donors












PI: Management & Care - Evaluating Islets












PI: Management & Care - Acessing Portal Vein for PI TX Procedures












PI: Management & Care - Overseeing the Infusion and Managing Immunosupression












PI: Perform Islet Isolation












PI: Observe Islet Isolation















Physician

Text Field











Organ

Drop Down

All Organs










Pathway

Drop Down

All Pathways










Hospital

Drop Down

All Existing TX

Hospitals










Time Frame at Hospital

Start

End











Calendar

Calendar








Signature Required For:

Drop Down FX

KI Conditional KI Eval

KI Combined



Name

Text Field



Title

Text Field












All Organs Included in OPTN Bylaws


Kidney & Liver


Intestine


Lung


Components that perform transplants in recipients less than 18 years old



Physicain Involvement


Date of Transplant or Procurement

Patient Identifier TX: MR#

Pro: Donor ID



KI & LI: Donor Type


KI & LI: Was this a pediatric transplant?

IN: Was this an isolated IN TX or Combined LI/IN or Multi-viscerl

TX?

LU: Did the recipient receive a combined H/L Transplant?


Liver


Heart


Drop Down (see all below)



Calendar



Text Field

Drop Down Deceased Living



Check if applicable

Drop Down Isolated IN TX Combined LI/IN

Multi-visceral TX



Check if applicable



Pre



Peri



Post


Date of Birth


Weight at Time of Transplant if <25 kg









Check if applicable


Check if applicable


Check if applicable


Calendar

Calc: DOT-DOB=Age


Primary Care of Newly Transplanted Recipients (including immediate post operative care )












Procurement Observation












Transplant Observation












Peds: Observation of Donor Evaluation,

Donation Process, and Management of Multi Organ Donors












KI: Evaluate Potential Recipients












KI: Evaluate Potential Living Donors












Health Resources and Services Administration Expiration Date: XX/XX/2023



Meaning/Action

Black Text

Headers

Red Text

IT function

Blue Text

Related options for IT function

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these are fields that are not required for the specified application


PUBLIC BURDEN STATEMENT


The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. 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 information collection is 0915- 0184 and it is valid until XX/XX/2023. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non- profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The 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 14N136B, Rockville, Maryland, 20857 or [email protected].



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleMembership
AuthorChristi Manner
File Modified0000-00-00
File Created2021-06-03

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