Forms and Documents

Document Name	Status
Form 23 Kidney Paired Donation Pilot Program (KPDPP) contact update Form Form and Instruction	Unchanged
Form 21 HOPE Act Variance Request Form Form and Instruction	Unchanged
Form 20 Additional Surgeon and Physician Request Form Form and Instruction	Unchanged
Form 19 Primary Data Coordinator Form Form and Instruction	Unchanged
Form 18 Primary Program Administrator Form Form and Instruction	Unchanged
Form 17 OPTN Individual Membership Application Form and Instruction	Unchanged
Form 16 OPTN Business Membership Application Form and Instruction	Unchanged
Form 15 OPTN Public Organization Membership Application Form and Instruction	Unchanged
Form 14 OPTN Medical Scientific Membership Application Form and Instruction	Unchanged
Form 13 OPTN Representative Form Form and Instruction	Unchanged
Form 12 OPTN Membership Application for Histocompatibility Labs Form and Instruction	Unchanged
Form 11 OPTN Membership Application for OPOs Form and Instruction	Unchanged
Form 10 OPTN Membership Application for Intestine Transplant Programs Form and Instruction	Modified
Form 9 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application Form and Instruction	Modified
Form 8 OPTN Membership Application Islet Transplant Program Form and Instruction	Modified
Form 7 B OPTN Membership Application for Lung Transplant Program Form and Instruction	Modified
Form 6 B OPTN Membership Application for Heart Transplant Program Form and Instruction	Modified
Form 5 B OPTN Membership Application for Pancreas Transplant Programs Form and Instruction	Modified
Form 4 B OPTN Membership Application for Liver Transplant Progrms Form and Instruction	Modified
Form 3 B OPTN Membership Application for Kidney Transplant Programs Form and Instruction	Modified
Form 1 OPTN Membership Application for Transplant Hospitals and Programs Form and Instruction	Modified
10072024 - Membership Non-Substantive Change Memo Updated - CLEAN.docx Justification for No Material/Nonsubstantive Change	2024-10-07
10062023 - Change Memo - 091820235005 - CLEAN.docx Justification for No Material/Nonsubstantive Change	2023-10-13
10252022 - Supporting Statement - OMB 0915-0184.docx Supporting Statement A	2022-11-18

IC Document Collections

IC ID	Document Title	Status
257000	Kidney Paired Donation Pilot Program (KPDPP) contact update Form Form and Instruction	Unchanged
256999	HOPE Act Variance Request Form Form and Instruction	Unchanged
256998	Additional Surgeon and Physician Request Form Form and Instruction	Unchanged
256997	Primary Data Coordinator Form Form and Instruction	Unchanged
256996	Primary Program Administrator Form Form and Instruction	Unchanged
226701	OPTN Individual Membership Application Form and Instruction	Unchanged
226700	OPTN Business Membership Application Form and Instruction	Unchanged
226699	OPTN Public Organization Membership Application Form and Instruction	Unchanged
226698	OPTN Medical Scientific Membership Application Form and Instruction	Unchanged
226695	OPTN Representative Form Form and Instruction	Unchanged
226694	OPTN Membership Application for Histocompatibility Labs Form and Instruction	Unchanged
226693	OPTN Membership Application for OPOs Form and Instruction	Unchanged
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
226686	OPTN Membership Application Islet Transplant Program Form and Instruction	Modified
226685	OPTN Membership Application for Lung Transplant Program Form and Instruction	Modified
226684	OPTN Membership Application for Heart Transplant Program Form and Instruction	Modified
226683	OPTN Membership Application for Pancreas Transplant Programs Form and Instruction	Modified
226682	OPTN Membership Application for Liver Transplant Progrms Form and Instruction	Modified
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

ICR Details

OMB Control No:	ICR Reference No:
Status:	Previous ICR Reference No:
Agency/Subagency:	Agency Tracking No:
Title:
Type of Information Collection:	Common Form ICR:
Type of Review Request:	Date Received in OIRA:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract:

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR?

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Number of Information Collection (IC) in this ICR: 0

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ICR Summary of Burden

	Total	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	0	0	0	0	0	0
Annual Time Burden (Hours)	0	0	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion:

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion:

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods?

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.    

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.    

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?

Is this ICR related to the Pandemic Response?

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Common Form ICR: 

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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:

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