| OPTN Pancreas Waiting Time Reinstatement Form |
| Fields to be completed by members |
|
|
|
| Form Section |
Field Label |
Notes |
| OPTN Pancreas Waiting Time |
CANDIDATE NAME |
|
| OPTN Pancreas Waiting Time |
CANDIDATE HIC #/SSN |
|
| OPTN Pancreas Waiting Time |
TRANSPLANT PROGRAM NAME/CODE |
|
| OPTN Pancreas Waiting Time |
DATE OF TRANSPLANT |
|
| OPTN Pancreas Waiting Time |
Patient has been re-listed |
|
| OPTN Pancreas Waiting Time |
OPTION 1: Removal of the Transplanted Pancreas |
|
| OPTN Pancreas Waiting Time |
Date of graft failure (must be within 14 days of transplant) |
|
| OPTN Pancreas Waiting Time |
Operative report for removal of transplanted pancreas |
|
| OPTN Pancreas Waiting Time |
OPTION 2: Statement of Intent |
|
| OPTN Pancreas Waiting Time |
Date of graft failure (must be within 14 days of transplant) |
|
| OPTN Pancreas Waiting Time |
TRANSPLANT PHYSICIAN/SURGEON SIGNATURE |
|
| OPTN Pancreas Waiting Time |
DATE |
|
| OPTN Pancreas Waiting Time |
TRANSPLANT PHYSICIAN/SURGEON NAME (Please print or type) |
|
| OPTN Pancreas Waiting Time |
Transplant Program Contact Name |
|
| OPTN Pancreas Waiting Time |
Transplant Program Contact Email |
|
| OPTN Pancreas Waiting Time |
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. |