OPTN Membership Application for Liver Transplant Progrms

Organ Procurement and Transplantation Network Application Form

Documents and Forms

Document Name Document Type
Form 4 B OPTN Membership Application for Liver Transplant Progrms Form and Instruction
4 B OPTN Membership Application_Surgeon or Physician Log OPTN Membership Application Surgeon or Physician Log.docx Form and Instruction
4 B OPTN Membership Application_Surgeon or Physician Log OPTN Membership Application Surgeon or Physician Log.docx Form and Instruction
4 OPTN Membership Application for Liver Transplant Program 09182023 - 04_OPTN Membership Application for Liver Transplant Programs - REDLINE.docx Form and Instruction
4 OPTN Membership Application for Liver Transplant Program 09182023 - 04_OPTN Membership Application for Liver Transplant Programs - REDLINE.docx Form and Instruction

Information Collection (IC) Details

IC Title:	OPTN Membership Application for Liver Transplant Progrms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4 B	OPTN Membership Application_Surgeon or Physician Log	OPTN Membership Application Surgeon or Physician Log.docx		Yes	Yes	Fillable Fileable
Form and Instruction	4	OPTN Membership Application for Liver Transplant Programs	09182023 - 04_OPTN Membership Application for Liver Transplant Programs - REDLINE.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 143	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	84	84
Annual IC Time Burden (Hours)	1,092	1,092
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.