Information Collection Request

Organ Procurement and Transplantation Network Application Form

ICR 202211-0915-001 · OMB 0915-0184 · Received in OIRA

⚠️ Notice: This information collection may be outdated.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

Forms and Documents

Document	Type	Status	Availability
Form 23 Kidney Paired Donation Pilot Program (KPDPP) contact update Form	Form and Instruction	New	Repair queued
Form 21 HOPE Act Variance Request Form	Form and Instruction	New	Repair queued
Form 20 Additional Surgeon and Physician Request Form	Form and Instruction	New	Repair queued
Form 19 Primary Data Coordinator Form	Form and Instruction	New	Repair queued
Form 18 Primary Program Administrator Form	Form and Instruction	New	Repair queued
Form 17 OPTN Individual Membership Application	Form and Instruction	Modified	Repair queued
Form 16 OPTN Business Membership Application	Form and Instruction	Modified	Repair queued
Form 15 OPTN Public Organization Membership Application	Form and Instruction	Modified	Repair queued
Form 14 OPTN Medical Scientific Membership Application	Form and Instruction	Modified	Repair queued
Form 13 OPTN Representative Form	Form and Instruction	Modified	Repair queued
Form 12 OPTN Membership Application for Histocompatibility Labs	Form and Instruction	Modified	Repair queued
Form 11 OPTN Membership Application for OPOs	Form and Instruction	Modified	Repair queued
Form 10 OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	Repair queued
Form 2 OPTN Certificate of Assessment and Program Coverage Plan Membership Application	Form and Instruction	Removed	Repair queued
Form 9 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified	Repair queued
Form 8 OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified	Repair queued
Form 7 OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified	Repair queued
Form 6 OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified	Repair queued
Form 5 OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	Repair queued
Form 4 OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified	Repair queued
Form 3 OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	Repair queued
Form 1 OPTN Membership Application for Transplant Hospitals and Programs	Form and Instruction	New	Repair queued
10252022 - Supporting Statement - OMB 0915-0184.docx	Supporting Statement A	Uploaded 2022-11-18	Repair queued

IC Document Collections

IC ID	Collection	Type	Status
257000	Kidney Paired Donation Pilot Program (KPDPP) contact update Form	Form and Instruction	New
256999	HOPE Act Variance Request Form	Form and Instruction	New
256998	Additional Surgeon and Physician Request Form	Form and Instruction	New
256997	Primary Data Coordinator Form	Form and Instruction	New
256996	Primary Program Administrator Form	Form and Instruction	New
226701	OPTN Individual Membership Application	Form and Instruction	Modified
226700	OPTN Business Membership Application	Form and Instruction	Modified
226699	OPTN Public Organization Membership Application	Form and Instruction	Modified
226698	OPTN Medical Scientific Membership Application	Form and Instruction	Modified
226695	OPTN Representative Form	Form and Instruction	Modified
226694	OPTN Membership Application for Histocompatibility Labs	Form and Instruction	Modified
226693	OPTN Membership Application for OPOs	Form and Instruction	Modified
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified
226689	OPTN Certificate of Assessment and Program Coverage Plan Membership Application	Form and Instruction	Removed
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified
226680	OPTN Membership Application for Transplant Hospitals and Programs	Form and Instruction	New

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/HSA
OMB Control No	0915-0184
Type of Information Collection	Revision of a currently approved collection
Previous ICR Reference No	202106-0915-002
Agency Tracking No	21566
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31