5B Membership_SurgeonOrPhysicianLog Form

Department of Health and Human Services Health Resources and Services Administration

OMB No. 0915-0184

Expiration Date: XX/XX/2023

OPTN Membership Application - Surgeon or Physician Log

Surgeon	Text Field
Organ	Drop Down	All Organs
Pathway	Drop Down	All Pathways
Hospital	Drop Down	All Existing TX Hospitals
Time Frame at Hospital	Start	End
	Calendar	Calendar
Signature Required For:	Drop Down Residency FX IN VCA PI	Name Text Field	Title Text Field
	All Organs Included in OPTN Bylaws			Kidney and LDK	Intestine	Lung	Vascular Composite Allograft		Pancreas Islet	Components that perform transplants in recipients less than 18 years old
Type of Procedure	Date of : Procedure/ Eval Date/Date of Care Provided	Patient Identifier TX: MR# Pro: Donor ID	Role of Surgeon	KI & LDK: Type of Donor	IN: Did the recovery also include the LI?	LU: Was this a combined H/L Transplant?	VCA: Other - Microvascular Procedure	VCA: Other - Name of Team Member with Microvascular Experience	PI: Was the Procedure Allogenic or Autologous?	Date of Birth	Weight at Time of Transplant if <25 kg
Drop Down (see all below)	Calendar	Text Field	Drop Down Primary Co-Surgeon First Assistant	Drop Down Deceased Living	Check if applicable	Check if applicable	Text Field	Text Field	Drop down	Calendar Calc: DOT-DOB=Age	Text Field
Transplant (can be multi organ if organ applying for is included) (Transplant must be in the VCA Type applying for)
Procurement (must include organ applying for)
LDK: Open Nephrectomy
LDK: Lap Nephrectomy
LDL: Major Liver Resection
LDL: Major Liver Resection-Live Donor
VCA: Multi-Organ Procurement Observation
VCA: Upper Limb - Pre-Op Eval of Potential TX Pts
VCA: Upper Limb - Post-Op Follow up of a Recipient for 1 Year
VCA: Upper Limb - Bone
VCA: Upper Limb - Nerve
VCA: Upper Limb - Tendon
VCA: Upper Limb - Skin or Wound Problems
VCA: Upper Limb - Contracture or Joint Stiffness
VCA: Upper Limb - Tumor
VCA: Upper Limb - Microsurgical Procedures Free Flaps
VCA: Upper Limb - Non-surgical Management
VCA: Upper Limb - Replantation or Transplant
VCA: Head & Neck - Pre-Op Eval of Potential TX Pts
VCA: Head & Neck - Post-Op Follow up of a Recipient for 1 Year
VCA: Head & Neck - Facial trauma with bone fixation
VCA: Head & Neck - Head or neck free tissue reconstruction
VCA: Other - Pre-Op Eval of Potential VCA TX Pts
VCA: Other - Microvascular Experience
PI: Management & Care of Islet Transplant Patients
PI: Management & Care - Selecting Donors
PI: Management & Care - Evaluating Islets
PI: Management & Care - Acessing Portal Vein for PI TX Procedures
PI: Management & Care - Overseeing the Infusion and Managing Immunosupression
PI: Perform Islet Isolation
PI: Observe Islet Isolation

Physician	Text Field
Organ	Drop Down	All Organs
Pathway	Drop Down	All Pathways
Hospital	Drop Down	All Existing TX Hospitals
Time Frame at Hospital	Start	End
	Calendar	Calendar
Signature Required For:	Drop Down FX KI Conditional KI Eval KI Combined	Name Text Field	Title Text Field
	All Organs Included in OPTN Bylaws		Kidney & Liver		Intestine	Lung	Components that perform transplants in recipients less than 18 years old
Physicain Involvement	Date of Transplant or Procurement	Patient Identifier TX: MR# Pro: Donor ID	KI & LI: Donor Type	KI & LI: Was this a pediatric transplant?	IN: Was this an isolated IN TX or Combined LI/IN or Multi-viscerl TX?	LU: Did the recipient receive a combined H/L Transplant?	Liver			Heart
Drop Down (see all below)	Calendar	Text Field	Drop Down Deceased Living	Check if applicable	Drop Down Isolated IN TX Combined LI/IN Multi-visceral TX	Check if applicable	Pre	Peri	Post	Date of Birth	Weight at Time of Transplant if <25 kg
							Check if applicable	Check if applicable	Check if applicable	Calendar Calc: DOT-DOB=Age
Primary Care of Newly Transplanted Recipients (including immediate post operative care )
Procurement Observation
Transplant Observation
Peds: Observation of Donor Evaluation, Donation Process, and Management of Multi Organ Donors
KI: Evaluate Potential Recipients
KI: Evaluate Potential Living Donors

Health Resources and Services Administration Expiration Date: XX/XX/2023

	Meaning/Action
Black Text	Headers
Red Text	IT function
Blue Text	Related options for IT function
Shaded Gray	these are fields that are not required for the specified application
	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- 0184 and it is valid until XX/XX/2023. 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 1 hour 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 Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.