13 OPTN Membership_Representative Form

Department of Health and Human Services OMB No. 0915-0184

Health Resources and Services Administration Expiration Date: xx/xx/20xx

OPTN Representative Form

CERTIFICATION

The undersigned, a duly authorized representative of the applicant, does hereby certify that the answers and attachments to this application are true, correct and complete, to the best of his or her knowledge after investigation. I understand that the intentional submission of false data to the OPTN may result in action by the Secretary of the Department of Health and Human Services, and/or civil or criminal penalties. By submitting this application to the OPTN, the applicant agrees: (i) to be bound by OPTN Obligations, including amendments thereto, if the applicant is granted membership and (ii) to be bound by the terms, thereof, including amendments thereto, in all matters relating to consideration of the application without regard to whether or not the applicant is granted membership.

If you have any questions, please call the UNOS Membership Team at 833-577-9469 or email MembershipRequests@unos.org.

Instructions:

For changes to the positions in this form, the current OPTN Representative, Alternate OPTN Representative, or Organization CEO must sign. The new individual being designated cannot provide the signature.

CEOs should sign-off on forms for new OPTN members.

OPTN Representative

____________________________ ____________________________ ____________________________

Printed Name Signature Email Address

Alternate OPTN Representative

____________________________ ____________________________ ____________________________

Printed Name Signature Email Address

Organization CEO

____________________________ ____________________________ ____________________________

Printed Name Signature Email Address

Part 1: General Information

Name of Organization: _________________________________________________________________

OPTN Member Code: ____________

Office Address

Street: ________________________________________ Suite: _______ Phone #: __________________

City: _______________________ State: _________ Zip: _____________ Fax #: ____________________

Mailing Address (if different from Office Address)

Street/P.O. Box: ____________________________________________

City: _______________________ State: _________ Zip: _____________

Name of Person Completing Form: _____________________________ Title: _____________________

Email Address of Person Completing Form: _________________________________________________

Date Form is submitted to OPTN Contractor: ____________________________

Part 2: OPTN Representatives

OPTN Representative

Name: ______________________________________ Job Title: ________________________________

Credentials (list all): ___________________________________________________________________

Street: _________________________________________ Suite: _______ Phone #: _________________

City: _______________________ State: _________ Zip: _____________ Fax #: ____________________

Email Address: _________________________________________________

OPTN Alternate Representative

Name: ______________________________________ Job Title: ________________________________

Credentials (list all): ___________________________________________________________________

Street: _________________________________________ Suite: _______ Phone #: _________________

City: _______________________ State: _________ Zip: _____________ Fax #: ____________________

Email Address: _________________________________________________

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/20xx. 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 0.25 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.

OPTN Rep-5