102 OPTN Waiting Time Modification Form

OPTN Waiting Time Modification Form
Fields to be completed by members
Form Section	Field Label	Notes
OPTN Waiting Time Modification	CANDIDATE NAME
OPTN Waiting Time Modification	WAITING LIST ORGAN
OPTN Waiting Time Modification	CANDIDATE HIC #/SSN
OPTN Waiting Time Modification	TRANSPLANT PROGRAM NAME/CODE
OPTN Waiting Time Modification	Explanation for request (continue on additional pages as necessary)
OPTN Waiting Time Modification	OPTION 1: Applications for Modifications of Waiting Time
OPTN Waiting Time Modification	Documentation showing an intent to register the candidate at the requested listing date
OPTN Waiting Time Modification	Requested listing date
OPTN Waiting Time Modification	Documentation that the candidate met criteria for waiting time accrual as of the listing date requested
OPTN Waiting Time Modification	Signatures indicating agreement from all transplant programs for the same organ type in the DSA
OPTN Waiting Time Modification	If the request is due to an error, miscommunication, or similar cause, document the implemented corrective action plan below
OPTN Waiting Time Modification	OPTION 2: Applications for Expedited Modifications of Waiting Time
OPTN Waiting Time Modification	An error occurred in removing the candidate's waiting list record
OPTN Waiting Time Modification	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
OPTN Waiting Time Modification	The candidate was removed from the waiting list for medical reasons, other than receiving a transplant
OPTN Waiting Time Modification	An islet recipient has re-registered on the islet waiting list
OPTN Waiting Time Modification	Corrective action plan
OPTN Waiting Time Modification	TRANSPLANT PHYSICIAN/SURGEON SIGNATURE
OPTN Waiting Time Modification	DATE
OPTN Waiting Time Modification	TRANSPLANT PHYSICIAN/SURGEON NAME (Please print or type)
OPTN Waiting Time Modification	Transplant Program Contact Name
OPTN Waiting Time Modification	Transplant Program Contact Email
OPTN Waiting Time Modification	Transplant Program Contact Phone Number
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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.