Non-US Transplants Reporting Form

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

Non-US Transplants Form

Within TIEDI^® users are able to register transplant events that occurred outside of the United States. This feature enables kidney programs to report medical criteria if kidney candidate is eligible for priority on kidney match due to prior liver transplant that occurred outside of the United States. This information is added to the OPTN database and does not generate additional forms.

Non-US Transplants

Transplant center: Select the transplant center from a drop-down list. This is a required field.

Recipient SSN: Enter the recipient Social Security Number (SSN). This is a required field. The SSN entered here should match the SSN on the candidate’s Waitlist^SM record. If a candidate is listed with a 9FN or 9CH number, that same number should be entered here to ensure that the non-US transplant appears on the kidney candidate’s Waitlist^SM record.

Recipient last name: Enter the recipient’s last name. This is a required field.

Recipient first name: Enter the recipient’s first name. This is a required field.

Recipient middle initial: Enter the recipient's middle initial, if applicable.

Recipient date of birth: Enter the recipient's date of birth. This is a required field.

Country transplant occurred: Select the country the transplant occurred from the drop-down list.

Transplant date: Enter the transplant date.

Organ: Select Liver as the type of transplanted organ.

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

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified	0000-00-00
File Created	2025-07-03