Form 103 Renal Waiting Time Reinstatement Form

OPTN Renal Waiting Time Reinstatement Form
Fields to be completed by members
Form Section	Field Label	Notes
OPTN Renal Waiting Time	CANDIDATE NAME
OPTN Renal Waiting Time	CANDIDATE SSN
OPTN Renal Waiting Time	TRANSPLANT PROGRAM NAME/CODE
OPTN Renal Waiting Time	DATE OF TRANSPLANT
OPTN Renal Waiting Time	Patient has been re-listed
OPTN Renal Waiting Time	A graft failure date, which is within 90 days of transplant, has been reported in TIEDI
OPTN Renal Waiting Time	Date of graft failure
OPTN Renal Waiting Time	OPTION 1: Kidney graft removal within 90 days of transplantation
OPTN Renal Waiting Time	Date of kidney graft removal
OPTN Renal Waiting Time	Operative report of removal of the transplanted kidney
OPTN Renal Waiting Time	OPTION 2: Kidney graft failure within 90 days of transplantation followed by non-function of the organ, evidenced by maintenance of the patient on dialysis or a creatinine clearance level/GFR ≤ 20 mL/min
OPTN Renal Waiting Time	Within the first 90 days of transplant
OPTN Renal Waiting Time	TRANSPLANT PHYSICIAL/SURGEON SIGNATURE
OPTN Renal Waiting Time	DATE
OPTN Renal Waiting Time	TRANSPLANT PHYSICIAN/SURGEON NAME (Please print or type)
OPTN Renal Waiting Time	Transplant Program Contact Name
OPTN Renal Waiting Time	Transplant Program Contact Email
OPTN Renal Waiting Time	Transplant Program Contact Phone Number
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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 0915-0157 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].