102. OPTN Wait Time Modification Form_Instructions

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

OPTN Wait Time Modification Form

OPTN Waiting Time Modification

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.

TRANSPLANT PROGRAM NAME/CODE: The name of the transplant program.

Explanation for request (continue on additional pages as necessary): Describe the reason the candidate’s waiting list time should be modified.

OPTION 1: Applications for Modifications of Waiting Time

To apply for a waiting time modification, the candidate’s transplant program must submit an application to the OPTN Contractor, to be reviewed by the appropriate organ-specific committee according to OPTN policy, with all of the following information:

• Documentation showing an intent to register the candidate at the requested listing date

Requested listing date

• Documentation that the candidate met criteria for waiting time accrual as of the listing date requested

• Signatures indicating agreement from all transplant programs for the same organ type in the DSA

• If the request is due to an error, miscommunication, or similar cause, document the implemented corrective action plan below

OPTION 2: Applications for Expedited Modifications of Waiting Time: Select this option if you are applying for an expedited modification of the candidate’s waiting time.

To apply for an expedited modification of waiting time, please check all of the following reasons for the request and if the request is due to an error, miscommunication, or similar cause, document the implemented corrective action plan below:

• An error occurred in removing the candidate's waiting list record

• An error occurred in registering, modifying, or renewing the candidate's waiting list record AND the patient is registered for Status 1 liver, pediatric Status 1A heart, adult Status 1, 2, 3, 4 heart, or pediatric Priority 1 lung

• The candidate was removed from the waiting list for medical reasons, other than receiving a transplant

• An islet recipient has re-registered on the islet waiting list

Corrective action plan: If the request is due to an error, miscommunication, or similar cause, document the implemented corrective action plan.

TRANSPLANT PHYSICIAN/SURGEON SIGNATURE: Signature of the transplant physician/surgeon.

DATE: Date on which the transplant physician/surgeon signed the form.

TRANSPLANT PHYSICIAN/SURGEON NAME (Please print or type): Print or type the transplant physician/surgeon’s name.

Transplant Program Contact Name: Enter the name of the appropriate contact person at the transplant program.

Transplant Program Contact Email: The contact’s email address.

Transplant Program Contact Phone Number: The contact’s 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.   

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