Organ Procurement and Transplantation Network Application Form

OMB 0915-0184

This is a request for OMB approval for revisions of the application documents used to collect information for determining if the interested party is compliant with membership requirements contained in the final rule Governing the Operation of the Organ Procurement and Transplantation Network (OPTN), (42 CFR part 121) ‘‘the OPTN final rule.’’ Respondents include: hospitals seeking to perform organ transplants, non-profit organizations seeking to become an organ procurement organization, and medical laboratories seeking to become an OPTN-approved histocompatibility laboratory.

The latest form for Organ Procurement and Transplantation Network Application Form expires 2023-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 23 Kidney Paired Donation Pilot Program (KPDPP) contact update Form Form and Instruction
Form 21 HOPE Act Variance Request Form Form and Instruction
Form 20 Additional Surgeon and Physician Request Form Form and Instruction
Form 19 Primary Data Coordinator Form Form and Instruction
Form 18 Primary Program Administrator Form Form and Instruction
Form 17 OPTN Individual Membership Application Form and Instruction
Form 16 OPTN Business Membership Application Form and Instruction
Form 15 OPTN Public Organization Membership Application Form and Instruction
Form 14 OPTN Medical Scientific Membership Application Form and Instruction
Form 13 OPTN Representative Form Form and Instruction
Form 12 OPTN Membership Application for Histocompatibility Labs Form and Instruction
Form 11 OPTN Membership Application for OPOs Form and Instruction
Form 10 OPTN Membership Application for Intestine Transplant Programs Form and Instruction
Form 9 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application Form and Instruction
Form 8 OPTN Membership Application Islet Transplant Program Form and Instruction
Form 7 B OPTN Membership Application for Lung Transplant Program Form and Instruction
Form 6 B OPTN Membership Application for Heart Transplant Program Form and Instruction
Form 5 B OPTN Membership Application for Pancreas Transplant Programs Form and Instruction
Form 4 B OPTN Membership Application for Liver Transplant Progrms Form and Instruction
Form 3 B OPTN Membership Application for Kidney Transplant Programs Form and Instruction
Form 1 OPTN Membership Application for Transplant Hospitals and Programs Form and Instruction
10062023 - Change Memo - 091820235005 - CLEAN.docx Justification for No Material/Nonsubstantive Change
10252022 - Supporting Statement - OMB 0915-0184.docx Supporting Statement A
Kidney Paired Donation Pilot Program (KPDPP) contact update Form Form and Instruction
HOPE Act Variance Request Form Form and Instruction
Additional Surgeon and Physician Request Form Form and Instruction
Primary Data Coordinator Form Form and Instruction
Primary Program Administrator Form Form and Instruction
OPTN Individual Membership Application Form and Instruction
OPTN Business Membership Application Form and Instruction
OPTN Public Organization Membership Application Form and Instruction
OPTN Medical Scientific Membership Application Form and Instruction
OPTN Representative Form Form and Instruction
OPTN Membership Application for Histocompatibility Labs 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 Vascularized Composite Allograft (VCA) Transplant Program Application 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 Heart Transplant Program 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 Kidney Transplant Programs Form and Instruction
OPTN Membership Application for Transplant Hospitals and Programs Form and Instruction

All Historical Document Collections

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

Federal Enterprise Architecture: Health - Health Care Services

Form 1

Membership_Transplant Hospital_General Form.docx

Fillable Fileable

Form and instruction

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