15 Membership_PublicOrg Form

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

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

OPTN Public Organization Membership Application

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].

OPTN Representative

________________________________________ ________________________________________

Print Name Signature

________________________________________ ________________________________________

Title Email Address

Alternate OPTN Representative

________________________________________ ________________________________________

Print Name Signature

________________________________________ ________________________________________

Title Email Address

Part 1: General Information

Name of Organization: _________________________________________________________________

OPTN Member Code: ____________

Office Address

Street: ________________________________________ Suite: _______ Phone #: __________________

City: _______________________ State: _________ Zip: _____________ Fax #: ____________________

Mailing Address (if different from Office Address)

Street/P.O. Box: ____________________________________________

City: _______________________ State: _________ Zip: _____________

Name of Person Completing Form: _____________________________ Title: _____________________

Email Address of Person Completing Form: _________________________________________________

Date Form is submitted to OPTN Contractor: ____________________________

Applying for:

☐ New Membership

☐ Membership Renewal

Part 2: General Requirements

A public organization member is an organization with an interest in organ donation or transplantation.

1. Date organization began operation: _________________________

2. Provide documentation that demonstrates that the organization has been in operation for at least one year. Documents may include:

• Organization's last annual report or annual financial report

• Organization's Articles of Incorporation and Bylaws

• Current roster of the organization's board of directors and officers

3. Which additional criteria for membership does the organization qualify?

Check at least one, and provide corresponding documentation

☐ A hospital that refers at least one potential organ or tissue donor per year.

☐ A non-profit organization that engages in organ donation activities, or represents or directly provides support and services to transplant candidates, recipients or their families.

☐ A non-profit organization that has letters of recommendation from at least three OPTN transplant hospital, OPO, histocompatibility laboratory, public organization, or medical/scientific members.

Provide an explanation for why the organization would like to be a new or renewing member of the OPTN:

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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 0.5 hour 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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