OPTN Certificate of Assessment and Program Coverage Plan Membership Application

Organ Procurement and Transplantation Network Application Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0184 can be found here:

Documents and Forms

Document Name Document Type
Form 2 OPTN Certificate of Assessment and Program Coverage Plan Membership Application Form and Instruction
2 Membership_CertificateAssessment_ProgramCoverage Form.do Membership_CertificateAssessment_ProgramCoverage Form.docx Form and Instruction
2 Membership_CertificateAssessment_ProgramCoverage Form.do Membership_CertificateAssessment_ProgramCoverage Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	OPTN Certificate of Assessment and Program Coverage Plan Membership Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	2	Membership_CertificateAssessment_ProgramCoverage Form.docx	Membership_CertificateAssessment_ProgramCoverage Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-2	2
Annual IC Time Burden (Hours)	-6	6
Annual IC Cost Burden (Dollars)	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.