Form 4 B 4 B OPTN Membership Application_Surgeon or Physician Log

Organ Procurement and Transplantation Network Application Form

OPTN Membership Application Surgeon or Physician Log

OPTN Membership Application for Liver Transplant Progrms

OMB: 0915-0184

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Primary Surgeon Log: Transplants


Name of Surgeon:

Organ:

Hospital: Time Frame at Hospital:

Signature Name:

Signature Title:

Signature: Date:




Pediatric Only


#

Type of Procedure

Transplant Date

Patient Identifier

Primary/Co

Surgeon

1st

Assistant

DOB

Age

at Tx

Weight

at Tx

Other Pathway Specific Details

1

Transplant









2

Transplant









3

Transplant









4

Transplant









5

Transplant









6

Transplant









7

Transplant









8

Transplant









9

Transplant









10

Transplant









11

Transplant









12

Transplant









13

Transplant









14

Transplant









15

Transplant









16

Transplant









17

Transplant









18

Transplant









19

Transplant









20

Transplant









21

Transplant









22

Transplant









23

Transplant









24

Transplant









25

Transplant









26

Transplant









27

Transplant









28

Transplant









29

Transplant









30

Transplant









31

Transplant









32

Transplant









33

Transplant









34

Transplant









35

Transplant









36

Transplant









37

Transplant









38

Transplant









39

Transplant









40

Transplant









41

Transplant









42

Transplant









43

Transplant









44

Transplant









45

Transplant









46

Transplant









47

Transplant









48

Transplant









49

Transplant









50

Transplant









51

Transplant









52

Transplant










Primary Surgeon Log: Procurements


Name of Surgeon:

Organ:

Hospital: Time Frame at Hospital: Signature Name: Signature Title:

Signature: Date:



Pediatric Only


#

Type of Procedure

Procurement Date

Patient Identifier

Primary/Co

Surgeon

1st

Assistant

DOB

Age

at Tx

Weight

at Tx

LD/DD

Open/Lap

Other Pathway Specific Details

1

Procurement











2

Procurement











3

Procurement











4

Procurement











5

Procurement











6

Procurement











7

Procurement











8

Procurement











9

Procurement











10

Procurement











11

Procurement











12

Procurement











13

Procurement











14

Procurement











15

Procurement











16

Procurement











17

Procurement











18

Procurement











19

Procurement











20

Procurement











21

Procurement











22

Procurement











23

Procurement











24

Procurement











25

Procurement











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 1.17 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].



Primary Physician Log: Recipient


Name of Physician:

Organ:

Hospital: Time Frame at Hospital:

Signature Name:

Signature Title:

Shape2 Signature: Date:



Pediatric Only



#


Physician Involvement


Transplant Date


Patient Identifier

Pre-Operative Patient Care

Newly Transplanted

Patient Care

Followed Patient for

months


DOB

Age at Tx

Weight at Tx


Other Pathway Specific Details

1

Recipient Care










2

Recipient Care










3

Recipient Care










4

Recipient Care










5

Recipient Care










6

Recipient Care










7

Recipient Care










8

Recipient Care










9

Recipient Care










10

Recipient Care










11

Recipient Care










12

Recipient Care










13

Recipient Care










14

Recipient Care










15

Recipient Care










16

Recipient Care










17

Recipient Care










18

Recipient Care










19

Recipient Care










20

Recipient Care










21

Recipient Care










22

Recipient Care










23

Recipient Care










24

Recipient Care










25

Recipient Care










26

Recipient Care










27

Recipient Care










28

Recipient Care










29

Recipient Care










30

Recipient Care










31

Recipient Care










32

Recipient Care










33

Recipient Care










34

Recipient Care










35

Recipient Care










36

Recipient Care










37

Recipient Care










38

Recipient Care










39

Recipient Care










40

Recipient Care










41

Recipient Care










42

Recipient Care










43

Recipient Care










44

Recipient Care










45

Recipient Care










46

Recipient Care










47

Recipient Care










48

Recipient Care










49

Recipient Care










50

Recipient Care











Primary Physician Log: Observations


Name of Physician:

Organ: Hospital:

Time Frame at Hospital: Signature Name:

Signature Title:

Signature: Date:




#

Physician Involvement

Procurement Date

Donor ID

LD/DD

1

Procurement Observation




2

Procurement Observation




3

Procurement Observation






Pediatric Only

#

Physician Involvement

Transplant Date

Patient Identifier

LD/DD

Age at Tx

1

Transplant Observation





2

Transplant Observation





3

Transplant Observation





Primary Physician Log: Evaluation


Name of Physician:

Organ: Hospital:

Time Frame at Hospital:

Signature Name:

Signature Title:

Signature: Date:





#

Physician Involvement

Evaluation Date

Patient Identifier

Recipient/

Living Donor

Other Pathway Specific Details

1

Evaluation





2

Evaluation





3

Evaluation





4

Evaluation





5

Evaluation





6

Evaluation





7

Evaluation





8

Evaluation





9

Evaluation





10

Evaluation





11

Evaluation





12

Evaluation





13

Evaluation





14

Evaluation





15

Evaluation





16

Evaluation





17

Evaluation





18

Evaluation





19

Evaluation





20

Evaluation





21

Evaluation





22

Evaluation





23

Evaluation





24

Evaluation





25

Evaluation





26

Evaluation





27

Evaluation





28

Evaluation





29

Evaluation





30

Evaluation





31

Evaluation





32

Evaluation





33

Evaluation





34

Evaluation





35

Evaluation





36

Evaluation





37

Evaluation






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 1.17 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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AuthorChristine Marshall
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File Created2023-10-15

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