Form 18 Primary Program Administrator Form

Organ Procurement and Transplantation Network Application Form

Primary Program Administrator Form

Primary Program Administrator Form

OMB: 0915-0184

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

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




Primary Program Administrator Form





CERTIFICATION

The undersigned 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



____________________________ ____________________________ ____________________________

Printed Name Signature Email Address







A primary program administrator is the identified administrative lead for the transplant program.



Name of Transplant Hospital: ___________________________________________________________



OPTN Member Code (4 Letters): ____________



This individual will be the Primary Program Administrator for the following organ type(s)/organization (please check below all that apply):


Kidney

Liver

Intestine

Pancreas

Islet

Heart

Lung

VCA – Head and Neck

VCA – Upper Limb

VCA – Lower Limb

VCA – Abdominal Wall

VCA – Musculoskeletal Composite Graft Segment

VCA – Spleen

VCA – Vascularized Gland

VCA – Uterus

VCA – External Male Genitalia

VCA – Other Genitourinary Organs


Name of Primary Program Administrator: ________________________________________________



Credentials: ________________________________________________________________________



Title at Hospital: _____________________________________________________________________



Phone Number: _____________________________________________________________________



Email: _____________________________________________________________________________



Requestor Name: _________________________________________________



Date Submitted to OPTN: __________________________________________



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 0.25 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].



PPA-4



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleMembership
AuthorRoger Vacovsky
File Modified0000-00-00
File Created2024-10-09

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