Form 23 Kidney Paired Donation Pilot Program (KPDPP) contact upd

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

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

Kidney Paired Donation Pilot Program (KPDPP) Contact Update 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].

UNet Security Administrator

______________________________ ___________________________ ________________________

Printed Name Signature Email Address

Transplant Hospital Name: __________________________________________

OPTN Member Code: ______________ Date Submitted: ______________________

To modify your email list, complete the table below and return to [email protected].

Individuals must be added to the UNOS membership database prior to being added to KPD (if not already listed).

	Name of individual(s) to be ADDED	Name of individual(s) to be DELETED
*Primary KPD Contact (usually the KPD/LD coordinator) One individual is required
*Alternate KPD Contact Maximum 2
**Financial Contact Maximum 3
Match offer support: Surgeons Nephrologists Administrators Social workers Other coordinators HLA lab contact OPO contact (if applicable) Others determined by TXC No Minimum or Maximum

*Primary and alternate contact information will appear on the “TXC Contact Information” sheet on the Match Response page and the KPD Message Board page when you receive an offer. This information allows transplant hospitals to transfer donor records and set up cross-matches.

**Financial Contact information will appear on the “TXC Contact Information” sheet. This information will allow financial clearance of the donors and recipients and facilitate execution of financial contracts.

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 1.63 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].

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