13 OPTN Membership_Representative Form

Organ Procurement and Transplantation Network Application Form

OPTN Representative Form

OMB: 0915-0184

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Department of Health and Human Services OMB No. 0915-0184

Health Resources and Services Administration Expiration Date: xx/xx/20xx

OPTN Representative Form


CERTIFICATION

The undersigned, a duly authorized representative of the applicant, does hereby certify that the answers and attachments to this application are true, correct and complete, to the best of his or her knowledge after investigation. I understand that the intentional submission of false data to the OPTN may result in action by the Secretary of the Department of Health and Human Services, and/or civil or criminal penalties. By submitting this application to the OPTN, the applicant agrees: (i) to be bound by OPTN Obligations, including amendments thereto, if the applicant is granted membership and (ii) to be bound by the terms, thereof, including amendments thereto, in all matters relating to consideration of the application without regard to whether or not the applicant is granted membership.

If you have any questions, please call the UNOS Membership Team at 833-577-9469 or email [email protected].


Instructions:


For changes to the positions in this form, the current OPTN Representative, Alternate OPTN Representative, or Organization CEO must sign. The new individual being designated cannot provide the signature.


CEOs should sign-off on forms for new OPTN members.




OPTN Representative



____________________________ ____________________________ ____________________________

Printed Name Signature Email Address


Alternate OPTN Representative



____________________________ ____________________________ ____________________________

Printed Name Signature Email Address


Organization CEO



____________________________ ____________________________ ____________________________

Printed Name Signature Email Address



Part 1: General Information



Name of Organization: _________________________________________________________________



OPTN Member Code: ____________

Office Address



Street: ________________________________________ Suite: _______ Phone #: __________________



City: _______________________ State: _________ Zip: _____________ Fax #: ____________________



Mailing Address (if different from Office Address)



Street/P.O. Box: ____________________________________________



City: _______________________ State: _________ Zip: _____________





Name of Person Completing Form: _____________________________ Title: _____________________



Email Address of Person Completing Form: _________________________________________________



Date Form is submitted to OPTN Contractor: ____________________________





Part 2: OPTN Representatives



OPTN Representative



Name: ______________________________________ Job Title: ________________________________



Credentials (list all): ___________________________________________________________________



Street: _________________________________________ Suite: _______ Phone #: _________________



City: _______________________ State: _________ Zip: _____________ Fax #: ____________________



Email Address: _________________________________________________





OPTN Alternate Representative



Name: ______________________________________ Job Title: ________________________________



Credentials (list all): ___________________________________________________________________



Street: _________________________________________ Suite: _______ Phone #: _________________



City: _______________________ State: _________ Zip: _____________ Fax #: ____________________

Email Address: _________________________________________________











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/20xx. 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 0.25 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].



OPTN Rep-5


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleMembership
AuthorRoger Vacovsky
File Modified0000-00-00
File Created2023-08-27

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