OPTN Membership Application Surgeon or Physician Log

Organ Procurement and Transplantation Network Application Form

Documents and Forms

Document Name Document Type
Form 22 OPTN Membership Application Surgeon or Physician Log Form and Instruction
22 OPTN Membership Application Surgeon or Physician Log 22_OPTN Membership Application Surgeon or Physician Log_CLEAN.docx Form and Instruction

Information Collection (IC) Details

IC Title:	OPTN Membership Application Surgeon or Physician Log	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	22	OPTN Membership Application Surgeon or Physician Log	22_OPTN Membership Application Surgeon or Physician Log_CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Organ Procurement and Transplantation Network (OPTN)/ Scientific Registry of Transplant Recipients (SRTR) Data System, HHS/ HRSA/HSB/DoT, 09-15-0055	FR Citation: 87 FR 46967

Number of Respondents: 1	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	0	0	0	0	0	0
Annual IC Time Burden (Hours)	0	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.