101. OPTN Wait Time Transfer Form_Instructions

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

OPTN Wait Time Transfer Form

Candidates must complete this form when registering at a new transplant program if they want their waiting list time to transfer as well. The information on this form will be available to all transplant programs listed on the form as documentation of the request to transfer waiting time. Please note that the completion of this form does not register the candidate at the new transplant program.

OPTN Wait Time Transfer

CANDIDATE NAME: Enter the candidate’s name.

WAITING LIST ORGAN: Enter the candidate’s waiting list organ.

CANDIDATE HIC #/SSN: Enter the candidate's HIC number or SSN.

DATE OF BIRTH: Enter the candidate’s date of birth.

Check here to confirm the candidate has been registered on the waiting list at the new transplant program: Select this checkbox to confirm the candidate has been registered at the new transplant program.

Please select one of the following waiting time transfer options and complete the information as indicated.

OPTION 1: Transfer Waiting Time and Remove from Earlier Transplant Program

I wish to transfer my accumulated waiting time from (Transplant Program Name/Code)

To my new listing at (Transplant Program Name/Code)

And in addition be removed from (Transplant Program Name/Code).

OPTION 2: Transfer Waiting Time and Maintain Multiple Registrations

I wish to transfer my accumulated waiting time from (Transplant Program Name/Code)

To my new listing at (Transplant Program Name/Code) and remain on the waiting list at both programs.

CANDIDATE SIGNATURE: Candidate’s signature.

DATE Date on which the candidate signed the form.

Transplant Program Contact Name

Transplant Program Contact Email

Transplant Program Contact 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 paperwork@hrsa.gov.   

OPTN Restricted