| OPTN Waiting Time Transfer Form |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| OPTN Wait Time Transfer |
CANDIDATE NAME |
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| OPTN Wait Time Transfer |
WAITING LIST ORGAN |
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| OPTN Wait Time Transfer |
CANDIDATE HIC #/SSN |
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| OPTN Wait Time Transfer |
DATE OF BIRTH |
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| OPTN Wait Time Transfer |
Check here to confirm the candidate has been registered on the waiting list at the new transplant program |
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| OPTN Wait Time Transfer |
OPTION 1: Transfer Waiting Time and Remove from Earlier Transplant Program |
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| OPTN Wait Time Transfer |
I wish to transfer my accumulated waiting time from (Transplant Program Name/Code) |
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| OPTN Wait Time Transfer |
To my new listing at (Transplant Program Name/Code) |
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| OPTN Wait Time Transfer |
And in addition be removed from (Transplant Program Name/Code) |
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| OPTN Wait Time Transfer |
OPTION 2: Transfer Waiting Time and Maintain Multiple Registrations |
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| OPTN Wait Time Transfer |
I wish to transfer my accumulated waiting time from (Transplant Program Name/Code) |
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| OPTN Wait Time Transfer |
To my new listing at (Transplant Program Name/Code) and remain on the waiting list at both programs |
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| OPTN Wait Time Transfer |
CANDIDATE SIGNATURE |
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| OPTN Wait Time Transfer |
DATE |
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| OPTN Wait Time Transfer |
Transplant Program Contact Name |
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| OPTN Wait Time Transfer |
Transplant Program Contact Email |
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| OPTN Wait Time Transfer |
Transplant Program Contact Phone Number |
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| OMB No. 0915-0157; Expiration Date: XX/XX/20XX |
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| PUBLIC BURDEN STATEMENT: |
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| 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 0915-0157 and it is valid until XX/XX/202X. 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 0.27 hours 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. |