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 is listed under ICR 202512-0915-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form 23 Information Security Contact Management Form	Form and Instruction
Form 23 Information Security Contact Management Form	Form and Instruction
Form 22 OPTN Membership Application Surgeon or Physician Log	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 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 18 Primary Program Administrator Form	Form and Instruction
Form 15 OPTN Individual Membership Application	Form and Instruction
Form 15 OPTN Individual Membership Application	Form and Instruction
Form 14 OPTN Business 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 13 OPTN Public Organization Membership Application	Form and Instruction
Form 12 OPTN Medical/Scientific Membership Application	Form and Instruction
Form 12 OPTN Medical Scientific Membership Application	Form and Instruction
Form 16 OPTN Representative Form	Form and Instruction
Form 16 OPTN Representative Form	Form and Instruction
Form 10 OPTN Membership Application for Histocompatibility Laboratories	Form and Instruction
Form 10 OPTN Membership Application for Histocompatibility Labs	Form and Instruction
Form 11 OPTN Membership Application for OPOs	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 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 7 OPTN Membership Application Islet Transplant Program	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 5 OPTN Membership Application for Heart Transplant Program	Form and Instruction
Form 4 OPTN Membership Application for Pancreas 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 3 OPTN Membership Application for Liver Transplant Progrms	Form and Instruction
Form 2 OPTN Membership Application for Kidney 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
Form 1 OPTN Membership Application for Transplant Hospitals and Programs	Form and Instruction
Final OPO owned lab written agreement clarification request.pdf	Public Comments
111225 PRIVACY ACT STATEMENT.docx	Supplementary Document
111225 PRIVACY ACT STATEMENT.docx	Supplementary Document
Comment 1_Falb_AOPO (10.14.2025).pdf	Public Comments
Comment 1_Falb_AOPO_Transmittal (10.14.2025).pdf	Public Comments
0915-0184 OPTN Membership Forms Supporting Statement_01162026.docx	Supporting Statement A
0915-0184 OPTN Membership Forms Supporting Statement_111225_CLEAN final.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

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

OMB Details

OPTN Membership Application for Transplant Hospitals and Programs

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
Form	Name	Electronic access	Type
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.