Organ Procurement and Transplantation Network Application Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 23 Kidney Paired Donation Pilot Program (KPDPP) contact update Form	Form and Instruction	Unchanged	Available
Form 23 Kidney Paired Donation Pilot Program (KPDPP) contact update Form	Form and Instruction	Unchanged	Available
Form 21 Hope Act Variance Request Form	Form and Instruction	Unchanged	Available
Form 21 HOPE Act Variance Request Form	Form and Instruction	Unchanged	Available
Form 20 Additional Surgeon and Physician Request Form	Form and Instruction	Unchanged	Available
Form 20 Additional Surgeon and Physician Request Form	Form and Instruction	Unchanged	Available
Form 19 Primary Data Coordinator	Form and Instruction	Unchanged	Available
Form 19 Primary Data Coordinator Form	Form and Instruction	Unchanged	Repair queued
Form 18 Primary Program Administrator Form	Form and Instruction	Unchanged	Available
Form 18 Primary Program Administrator Form	Form and Instruction	Unchanged	Repair queued
Form 17 OPTN Membership_Individual Form	Form and Instruction	Unchanged	Available
Form 17 OPTN Individual Membership Application	Form and Instruction	Unchanged	Repair queued
Form 16 OPTN Membership_Business Form	Form and Instruction	Unchanged	Available
Form 16 OPTN Business Membership Application	Form and Instruction	Unchanged	Repair queued
Form 15 Membership_PublicOrg Form.docx	Form and Instruction	Unchanged	Available
Form 15 OPTN Public Organization Membership Application	Form and Instruction	Unchanged	Available
Form 14 Membership_MedicalScientific Form.docx	Form and Instruction	Unchanged	Repair queued
Form 14 OPTN Medical Scientific Membership Application	Form and Instruction	Unchanged	Repair queued
Form 13 OPTN Membership_Representative Form.docx	Form and Instruction	Unchanged	Available
Form 13 OPTN Representative Form	Form and Instruction	Unchanged	Available
Form 12 OPTN Membership Application for Histocompatibility Laboratories	Form and Instruction	Unchanged	Available
Form 12 OPTN Membership Application for Histocompatibility Labs	Form and Instruction	Unchanged	Repair queued
Form 11 Membership_OPO Form.docx	Form and Instruction	Unchanged	Available
Form 11 OPTN Membership Application for OPOs	Form and Instruction	Unchanged	Repair queued
Form 10 10_OPTN Membership Application for Intestine Transplant Programs REDLINE 10072024	Form and Instruction	Modified	Available
Form 10 10_OPTN Membership Application for Intestine Transplant Programs CLEAN 10072024	Form and Instruction	Modified	Available
Form 10 B OPTN Membership Application_Surgeon or Physician Log	Form and Instruction	Modified	Available
Form 10 OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	Available
Form 10 OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	Available
Form 9 09_OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs REDLINE 10072024	Form and Instruction	Modified	Available
Form 9 09_OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs CLEAN 10072024	Form and Instruction	Modified	Repair queued
Form 9 B OPTN Membership Application_Surgeon or Physician Log	Form and Instruction	Modified	Available
Form 9 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs	Form and Instruction	Modified	Available
Form 9 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified	Repair queued
Form 8 08_OPTN Membership Application for Islet Transplant Programs REDLINE 10072024	Form and Instruction	Modified	Available
Form 8 08_OPTN Membership Application for Islet Transplant Programs CLEAN 10072024	Form and Instruction	Modified	Available
Form 8 B OPTN Membership Application_Surgeon or Physician Log	Form and Instruction	Modified	Available
Form 8 OPTN Membership Application for Islet Transplant Programs CLEAN	Form and Instruction	Modified	Available
Form 8 OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified	Repair queued
Form 7 07_OPTN Membership Application for Lung Transplant Programs REDLINE 10072024	Form and Instruction	Modified	Available
Form 7 07_OPTN Membership Application for Lung Transplant Programs CLEAN 10072024	Form and Instruction	Modified	Available
Form 7 OPTN Membership Application for Lung Transplant Programs	Form and Instruction	Modified	Available
Form 7 B OPTN Membership Application_Surgeon or Physician Log	Form and Instruction	Modified	Available
Form 7 B OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified	Repair queued
Form 6 06_OPTN Membership Application for Heart Transplant Programs REDLINE 10072024	Form and Instruction	Modified	Available
Form 6 06_OPTN Membership Application for Heart Transplant Programs CLEAN 10072024	Form and Instruction	Modified	Available
Form 6 OPTN Membership Application for Heart Transplant Programs	Form and Instruction	Modified	Available
Form 6 B OPTN Membership Application_Surgeon or Physician Log	Form and Instruction	Modified	Available
Form 6 B OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified	Repair queued
Form 5 05_OPTN Membership Application for Pancreas Transplant Programs REDLINE 10072024	Form and Instruction	Modified	Available
Form 5 05_OPTN Membership Application for Pancreas Transplant Programs CLEAN 10072024	Form and Instruction	Modified	Available
Form 5 OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	Available
Form 5 B OPTN Membership Application_Surgeon or Physician Log	Form and Instruction	Modified	Available
Form 5 B OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	Repair queued
Form 4 04_OPTN Membership Application for Liver Transplant Programs REDLINE 10072024	Form and Instruction	Modified	Available
Form 4 04_OPTN Membership Application for Liver Transplant Programs CLEAN 10072024	Form and Instruction	Modified	Repair queued
Form 4 OPTN Membership Application for Liver Transplant Programs	Form and Instruction	Modified	Repair queued
Form 4 B OPTN Membership Application_Surgeon or Physician Log	Form and Instruction	Modified	Available
Form 4 B OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified	Available
Form 3 03_OPTN Membership Application for Kidney Transplant Programs REDLINE 10072024	Form and Instruction	Modified	Available
Form 3 03_OPTN Membership Application for Kidney Transplant Programs CLEAN 10072024	Form and Instruction	Modified	Available
Form 3 OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	Available
Form 3 B OPTN Membership Application_Surgeon or Physician Log.docx	Form and Instruction	Modified	Available
Form 3 B OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	Repair queued
Form 1 01_OPTN Membership Application for Transplant Hospitals and Programs REDLINE 10072024	Form and Instruction	Modified	Available
Form 1 01_OPTN Membership Application for Transplant Hospitals and Programs CLEAN 10072024	Form and Instruction	Modified	Available
Form 1 OPTN Membership Application for Transplant Hospitals and Programs.docx	Form and Instruction	Modified	Available
Form 1 OPTN Membership Application for Transplant Hospitals and Programs	Form and Instruction	Modified	Repair queued
10072024 - Membership Non-Substantive Change Memo Updated - CLEAN.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-10-07	Repair queued
10072024 - Membership Non-Substantive Change Memo Updated - CLEAN.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-10-07	Available
10062023 - Change Memo - 091820235005 - CLEAN.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-10-13	Repair queued
10062023 - Change Memo - 091820235005 - CLEAN.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-10-13	Available
10252022 - Supporting Statement - OMB 0915-0184.docx	Supporting Statement A	Uploaded 2022-11-18	Available
10252022 - Supporting Statement - OMB 0915-0184.docx	Supporting Statement A	Uploaded 2022-11-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
257000	Kidney Paired Donation Pilot Program (KPDPP) contact update Form	Form and Instruction	Unchanged	Kidney Paired Donation Pilot Program (KPDPP) contact update Form
257000	Kidney Paired Donation Pilot Program (KPDPP) contact update Form	Form and Instruction	Unchanged
256999	HOPE Act Variance Request Form	Form and Instruction	Unchanged	Hope Act Variance Request Form
256999	HOPE Act Variance Request Form	Form and Instruction	Unchanged
256998	Additional Surgeon and Physician Request Form	Form and Instruction	Unchanged	Additional Surgeon and Physician Request Form
256998	Additional Surgeon and Physician Request Form	Form and Instruction	Unchanged
256997	Primary Data Coordinator Form	Form and Instruction	Unchanged	Primary Data Coordinator
256997	Primary Data Coordinator Form	Form and Instruction	Unchanged
256996	Primary Program Administrator Form	Form and Instruction	Unchanged	Primary Program Administrator Form
256996	Primary Program Administrator Form	Form and Instruction	Unchanged
226701	OPTN Individual Membership Application	Form and Instruction	Unchanged	OPTN Membership_Individual Form
226701	OPTN Individual Membership Application	Form and Instruction	Unchanged
226700	OPTN Business Membership Application	Form and Instruction	Unchanged	OPTN Membership_Business Form
226700	OPTN Business Membership Application	Form and Instruction	Unchanged
226699	OPTN Public Organization Membership Application	Form and Instruction	Unchanged	Membership_PublicOrg Form.docx
226699	OPTN Public Organization Membership Application	Form and Instruction	Unchanged
226698	OPTN Medical Scientific Membership Application	Form and Instruction	Unchanged	Membership_MedicalScientific Form.docx
226698	OPTN Medical Scientific Membership Application	Form and Instruction	Unchanged
226695	OPTN Representative Form	Form and Instruction	Unchanged	OPTN Membership_Representative Form.docx
226695	OPTN Representative Form	Form and Instruction	Unchanged
226694	OPTN Membership Application for Histocompatibility Labs	Form and Instruction	Unchanged	OPTN Membership Application for Histocompatibility Laboratories
226694	OPTN Membership Application for Histocompatibility Labs	Form and Instruction	Unchanged
226693	OPTN Membership Application for OPOs	Form and Instruction	Unchanged	Membership_OPO Form.docx
226693	OPTN Membership Application for OPOs	Form and Instruction	Unchanged
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	10_OPTN Membership Application for Intestine Transplant Programs REDLINE 10072024
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	10_OPTN Membership Application for Intestine Transplant Programs CLEAN 10072024
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	OPTN Membership Application for Intestine Transplant Programs
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified	09_OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs REDLINE 10072024
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified	09_OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs CLEAN 10072024
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified	08_OPTN Membership Application for Islet Transplant Programs REDLINE 10072024
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified	08_OPTN Membership Application for Islet Transplant Programs CLEAN 10072024
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified	OPTN Membership Application for Islet Transplant Programs CLEAN
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified	07_OPTN Membership Application for Lung Transplant Programs REDLINE 10072024
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified	07_OPTN Membership Application for Lung Transplant Programs CLEAN 10072024
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified	OPTN Membership Application for Lung Transplant Programs
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified	06_OPTN Membership Application for Heart Transplant Programs REDLINE 10072024
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified	06_OPTN Membership Application for Heart Transplant Programs CLEAN 10072024
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified	OPTN Membership Application for Heart Transplant Programs
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	05_OPTN Membership Application for Pancreas Transplant Programs REDLINE 10072024
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	05_OPTN Membership Application for Pancreas Transplant Programs CLEAN 10072024
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	OPTN Membership Application for Pancreas Transplant Programs
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified	04_OPTN Membership Application for Liver Transplant Programs REDLINE 10072024
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified	04_OPTN Membership Application for Liver Transplant Programs CLEAN 10072024
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified	OPTN Membership Application for Liver Transplant Programs
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	03_OPTN Membership Application for Kidney Transplant Programs REDLINE 10072024
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	03_OPTN Membership Application for Kidney Transplant Programs CLEAN 10072024
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	OPTN Membership Application for Kidney Transplant Programs
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log.docx
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified
226680	OPTN Membership Application for Transplant Hospitals and Programs	Form and Instruction	Modified	01_OPTN Membership Application for Transplant Hospitals and Programs REDLINE 10072024
226680	OPTN Membership Application for Transplant Hospitals and Programs	Form and Instruction	Modified	01_OPTN Membership Application for Transplant Hospitals and Programs CLEAN 10072024
226680	OPTN Membership Application for Transplant Hospitals and Programs	Form and Instruction	Modified	OPTN Membership Application for Transplant Hospitals and Programs.docx
226680	OPTN Membership Application for Transplant Hospitals and Programs	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0184	ICR Reference No: 202410-0915-001
Status: Historical Active	Previous ICR Reference No: 202310-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No: 21566
Title: Organ Procurement and Transplantation Network Application Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/31/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/08/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2025	12/31/2025	12/31/2025
Responses	858	0	858
Time Burden (Hours)	5,610	0	5,610
Cost Burden (Dollars)	0	0	0

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Abstract: This is a request to revise the current Organ Procurement and Transplantation Network (OPTN) data collection associated with institutional (including transplant hospital, organ procurement organization, and transplant histocompatibility laboratory) and non-institutional (medical/scientific and public organization, business and individual) applications to meet or sustain requirements for OPTN membership. This request include adding two new data collection forms (Hope Act Variance Request and Kidney Paired Donation Pilot Program or KPDPP contact update form), three standalone forms (Primary Program Administrator, Primary Data Coordinator, and Additional Surgeon and Physician) for revised data collection, and a revision of organ-specific applications found in the Certificate of Assessment and Program Coverage Plan Membership Application (COA/PCP). The likely respondents are new and existing transplant hospitals, organ procurement organization, histocompatibility laboratories, medical/scientific organization, public organization, business and individual members.

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Authorizing Statute(s): US Code: 42 USC 1138 Name of Law: Hospital Protocols for Organ Procurement and Standards for Organ Procurement Agencies
   US Code: 42 USC 273 Name of Law: National Organ Transplant Act of 1984
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 52389	08/25/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 68713	11/16/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 21

table that charts list of burden

IC Title	Form No.	Form Name
Additional Surgeon and Physician Request Form	20	Additional Surgeon and Physician Request Form
HOPE Act Variance Request Form	21	Hope Act Variance Request Form
Kidney Paired Donation Pilot Program (KPDPP) contact update Form	23	Kidney Paired Donation Pilot Program (KPDPP) contact update Form
OPTN Business Membership Application	16	OPTN Membership_Business Form
OPTN Individual Membership Application	17	OPTN Membership_Individual Form
OPTN Medical Scientific Membership Application	14	Membership_MedicalScientific Form.docx
OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	9 , 9 B, 9, 9	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs ,   OPTN Membership Application_Surgeon or Physician Log ,   09_OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs CLEAN 10072024 ,   09_OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs REDLINE 10072024
OPTN Membership Application Islet Transplant Program	8, 8 B, 8, 8	OPTN Membership Application for Islet Transplant Programs CLEAN ,   OPTN Membership Application_Surgeon or Physician Log ,   08_OPTN Membership Application for Islet Transplant Programs CLEAN 10072024 ,   08_OPTN Membership Application for Islet Transplant Programs REDLINE 10072024
OPTN Membership Application for Heart Transplant Program	6 B, 6, 6, 6	OPTN Membership Application_Surgeon or Physician Log ,   OPTN Membership Application for Heart Transplant Programs ,   06_OPTN Membership Application for Heart Transplant Programs CLEAN 10072024 ,   06_OPTN Membership Application for Heart Transplant Programs REDLINE 10072024
OPTN Membership Application for Histocompatibility Labs	12	OPTN Membership Application for Histocompatibility Laboratories
OPTN Membership Application for Intestine Transplant Programs	10, 10, 10, 10 B	OPTN Membership Application for Intestine Transplant Programs ,   OPTN Membership Application_Surgeon or Physician Log ,   10_OPTN Membership Application for Intestine Transplant Programs CLEAN 10072024 ,   10_OPTN Membership Application for Intestine Transplant Programs REDLINE 10072024
OPTN Membership Application for Kidney Transplant Programs	3 B, 3, 3, 3	OPTN Membership Application_Surgeon or Physician Log.docx ,   OPTN Membership Application for Kidney Transplant Programs ,   03_OPTN Membership Application for Kidney Transplant Programs CLEAN 10072024 ,   03_OPTN Membership Application for Kidney Transplant Programs REDLINE 10072024
OPTN Membership Application for Liver Transplant Progrms	4, 4, 4, 4 B	OPTN Membership Application_Surgeon or Physician Log ,   OPTN Membership Application for Liver Transplant Programs ,   04_OPTN Membership Application for Liver Transplant Programs CLEAN 10072024 ,   04_OPTN Membership Application for Liver Transplant Programs REDLINE 10072024
OPTN Membership Application for Lung Transplant Program	7 B, 7, 7, 7	OPTN Membership Application_Surgeon or Physician Log ,   OPTN Membership Application for Lung Transplant Programs ,   07_OPTN Membership Application for Lung Transplant Programs CLEAN 10072024 ,   07_OPTN Membership Application for Lung Transplant Programs REDLINE 10072024
OPTN Membership Application for OPOs	11	Membership_OPO Form.docx
OPTN Membership Application for Pancreas Transplant Programs	5, 5 B, 5, 5	OPTN Membership Application_Surgeon or Physician Log ,   OPTN Membership Application for Pancreas Transplant Programs ,   05_OPTN Membership Application for Pancreas Transplant Programs CLEAN 10072024 ,   05_OPTN Membership Application for Pancreas Transplant Programs REDLINE 10072024
OPTN Membership Application for Transplant Hospitals and Programs	1, 1, 1	OPTN Membership Application for Transplant Hospitals and Programs.docx ,   01_OPTN Membership Application for Transplant Hospitals and Programs CLEAN 10072024 ,   01_OPTN Membership Application for Transplant Hospitals and Programs REDLINE 10072024
OPTN Public Organization Membership Application	15	Membership_PublicOrg Form.docx
OPTN Representative Form	13	OPTN Membership_Representative Form.docx
Primary Data Coordinator Form	19	Primary Data Coordinator
Primary Program Administrator Form	18	Primary Program Administrator Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	858	858	0	0	0	0
Annual Time Burden (Hours)	5,610	5,610	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $347,361

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/08/2024

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