OMB control number

Organ Procurement and Transplantation Network Application Form

OMB 0915-0184 · HHS/HSA.

OMB 0915-0184

This is a request to revise the current Organ Procurement and Transplantation Network (OPTN) data collection associated with institutional (including transplant hospital, organ procurement organization, and transplant histocompatibility laboratory) and non-institutional (medical/scientific and public organization, business and individual) applications to meet or sustain requirements for OPTN membership. This request include adding two new data collection forms (Hope Act Variance Request and Kidney Paired Donation Pilot Program or KPDPP contact update form), three standalone forms (Primary Program Administrator, Primary Data Coordinator, and Additional Surgeon and Physician) for revised data collection, and a revision of organ-specific applications found in the Certificate of Assessment and Program Coverage Plan Membership Application (COA/PCP). The likely respondents are new and existing transplant hospitals, organ procurement organization, histocompatibility laboratories, medical/scientific organization, public organization, business and individual members.

The latest form for Organ Procurement and Transplantation Network Application Form expires 2029-02-28 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 23 Information Security Contact Management Form Form and Instruction
Form 22 OPTN Membership Application Surgeon or Physician Log Form and Instruction
Form 21 Kidney Paired Donation Pilot Program (KPDPP) contact update form Form and Instruction
Form 20 HOPE Act Variance Request Form Form and Instruction
Form 20 HOPE Act Variance Request Form Form and Instruction
Form 19 Additional Surgeon and Physician Request Form Form and Instruction
Form 19 Additional Surgeon and Physician Request Form Form and Instruction
Form 17 Primary Data Coordinator Form Form and Instruction
Form 17 Primary Data Coordinator Form Form and Instruction
Form 18 Primary Program Administrator Form Form and Instruction
Form 15 OPTN Individual Membership Application Form and Instruction
Form 14 OPTN Business Membership Application Form and Instruction
Form 13 OPTN Public Organization Membership Application Form and Instruction
Form 12 OPTN Medical/Scientific Membership Application Form and Instruction
Form 16 OPTN Representative Form Form and Instruction
Form 10 OPTN Membership Application for Histocompatibility Laboratories Form and Instruction
Form 11 OPTN Membership Application for OPOs Form and Instruction
Form 9 OPTN Membership Application for Intestine Transplant Programs Form and Instruction
Form 9 OPTN Membership Application for Intestine Transplant Programs Form and Instruction
Form 8 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs Form and Instruction
Form 7 OPTN Membership Application for Islet Transplant Programs Form and Instruction
Form 6 OPTN Membership Application for Lung Transplant Programs Form and Instruction
Form 6 OPTN Membership Application for Lung Transplant Program Form and Instruction
Form 5 OPTN Membership Application for Heart Transplant Programs Form and Instruction
Form 4 OPTN Membership Application for Pancreas Transplant Programs Form and Instruction
Form 3 OPTN Membership Application for Liver Transplant Programs Form and Instruction
Form 2 OPTN Membership Application for Kidney Transplant Programs Form and Instruction
Form 1 OPTN Membership Application for Transplant Hospitals and Programs Form and Instruction
Final OPO owned lab written agreement clarification request.pdf (document unavailable) Public Comments
111225 PRIVACY ACT STATEMENT.docx Supplementary Document
Comment 1_Falb_AOPO (10.14.2025).pdf (document unavailable) Public Comments
Comment 1_Falb_AOPO_Transmittal (10.14.2025).pdf (document unavailable) Public Comments
0915-0184 OPTN Membership Forms Supporting Statement_01162026.docx Supporting Statement A
Information Security Contact Management Form Form and Instruction
Information Security Contact Management Form Form and Instruction
OPTN Membership Application Surgeon or Physician Log Form and Instruction
OPTN Membership Application Surgeon or Physician Log Form and Instruction
Kidney Paired Donation Pilot Program (KPDPP) contact update Form Form and Instruction
Kidney Paired Donation Pilot Program (KPDPP) contact update Form Form and Instruction
HOPE Act Variance Request Form Form and Instruction
HOPE Act Variance Request Form Form and Instruction
Additional Surgeon and Physician Request Form Form and Instruction
Additional Surgeon and Physician Request Form Form and Instruction
Primary Data Coordinator Form Form and Instruction
Primary Data Coordinator Form Form and Instruction
Primary Program Administrator Form Form and Instruction
Primary Program Administrator Form Form and Instruction
OPTN Individual Membership Application Form and Instruction
OPTN Individual Membership Application Form and Instruction
OPTN Business Membership Application Form and Instruction
OPTN Business Membership Application Form and Instruction
OPTN Public Organization Membership Application Form and Instruction
OPTN Public Organization Membership Application Form and Instruction
OPTN Medical Scientific Membership Application Form and Instruction
OPTN Medical Scientific Membership Application Form and Instruction
OPTN Representative Form Form and Instruction
OPTN Representative Form Form and Instruction
OPTN Membership Application for Histocompatibility Labs Form and Instruction
OPTN Membership Application for Histocompatibility Labs Form and Instruction
OPTN Membership Application for OPOs Form and Instruction
OPTN Membership Application for OPOs Form and Instruction
OPTN Membership Application for Intestine Transplant Programs Form and Instruction
OPTN Membership Application for Intestine Transplant Programs Form and Instruction
OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs Form and Instruction
OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs Form and Instruction
OPTN Membership Application Islet Transplant Program Form and Instruction
OPTN Membership Application Islet Transplant Program Form and Instruction
OPTN Membership Application for Lung Transplant Program Form and Instruction
OPTN Membership Application for Lung Transplant Program Form and Instruction
OPTN Membership Application for Heart Transplant Program Form and Instruction
OPTN Membership Application for Heart Transplant Program Form and Instruction
OPTN Membership Application for Pancreas Transplant Programs Form and Instruction
OPTN Membership Application for Pancreas Transplant Programs Form and Instruction
OPTN Membership Application for Liver Transplant Progrms Form and Instruction
OPTN Membership Application for Liver Transplant Progrms Form and Instruction
OPTN Membership Application for Kidney Transplant Programs Form and Instruction
OPTN Membership Application for Kidney Transplant Programs Form and Instruction
OPTN Membership Application for Transplant Hospitals and Programs Form and Instruction
OPTN Membership Application for Transplant Hospitals and Programs Form and Instruction

All Historical Document Collections

202512-0915-001 Approved without change	Revision of a currently approved collection	2025-12-10
202502-0915-003	No material or nonsubstantive change to a currently approved collection	2025-03-28
202410-0915-001	No material or nonsubstantive change to a currently approved collection	2024-10-08
202310-0915-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-10-13
202211-0915-001 Approved without change	Revision of a currently approved collection	2022-11-28
202106-0915-002 Approved with change	No material or nonsubstantive change to a currently approved collection	2021-06-02
202006-0915-007 Approved without change	Revision of a currently approved collection	2020-06-29
201906-0915-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2019-06-05
201802-0915-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2018-02-28
201705-0915-002 Approved without change	Revision of a currently approved collection	2017-05-12
201403-0915-002 Approved with change	Revision of a currently approved collection	2014-03-17
201102-0915-005 Approved without change	Revision of a currently approved collection	2011-02-24
200712-0915-001 Approved without change	Revision of a currently approved collection	2007-12-13
200406-0915-001 Approved without change	Revision of a currently approved collection	2004-06-07
200105-0915-001 Approved without change	Revision of a currently approved collection	2001-05-10
199803-0915-002 Approved without change	Revision of a currently approved collection	1998-03-27
199409-0915-003 Approved without change	New collection (Request for a new OMB Control Number)	1994-09-26

OMB Details

OPTN Membership Application for Transplant Hospitals and Programs

Federal Enterprise Architecture: Health - Health Care Services

Form 1

OPTN Membership Application for Transplant Hospitals and Programs

Fillable Fileable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.