Prior Living Donor Priority

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

Prior Living Donor Priority Request Form

This form can be submitted when a patient currently listed on the waiting list donated at least one organ within the United States or its territories. This form, or a letter containing the information required by policy, can be printed, completed, signed by a physician, and faxed to UNOS.

A candidate will be classified as a prior living donor if the candidate donated for transplantation, within the United States or its territories, at least one organ and the candidate’s physician reports all of the following information to the OPTN:

1. The name of the recipient or intended recipient of the donated organ or organ segment

2. The recipient’s or intended recipient’s transplant hospital

3. The date the donated organ was procured

The prior living donor priority a candidate receives will be determined by the policy specific to the organ donated.

Prior Living Donor Priority

Donor Name: Enter the donor’s name.

Donor HIC #/SSN: Enter the donor’s HIC number or SSN.

Date of Birth: Enter the donor’s date of birth.

Donation Date: Enter the date of the prior donation.

Recipient/Intended Recipient: Enter the name of the prior donation recipient.

Recipient Transplant Hospital Name/Code: Enter the name/code of the recipient’s transplant hospital.

Donor's Relationship to Recipient (if known): Describe the relationship between the donor and the recipient if known.

Requesting Transplant Center Name/Code: Enter the name/code of the transplant center requesting the prior living donor priority.

TRANSPLANT PHYSICIAN/SURGEON NAME (Please print or type): Print or type the name of the requesting transplant physical or surgeon.

Transplant Program Contact Name: Enter the name of the appropriate contact person at the transplant program.

Transplant Program Contact Email: The contact’s email address.

Transplant Program Contact Phone Number: The contact’s phone number.

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].   

OPTN Restricted