68 Donor Hospital Registration

Donor Hospital Registration
Fields to be completed by members
Form Section	Field Label	Notes
Request New Donor Hospital	CMS hospital name
Request New Donor Hospital	DonorNet donor hospital ID	Display only
Request New Donor Hospital	Provider ID
Request New Donor Hospital	Display name
Request New Donor Hospital	Status
Request New Donor Hospital	Street address
Request New Donor Hospital	Does this donor hospital need to be an available option when adding a new donor?
Request New Donor Hospital	City
Request New Donor Hospital	Trauma level
Request New Donor Hospital	State
Request New Donor Hospital	Time Zone
Request New Donor Hospital	ZIP code
Request New Donor Hospital	Is Daylight Savings Time observed?
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 0915-0157 and it is valid until XX/XX/202X. 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 0.27 hours 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].