Form 4 B 4 B OPTN Membership Application_Surgeon or Physician Log

Primary Surgeon Log: Transplants

Name of Surgeon:

Organ:

Hospital: Time Frame at Hospital:

Signature Name:

Signature Title:

Signature: Date:

						Pediatric Only
#	Type of Procedure	Transplant Date	Patient Identifier	Primary/Co Surgeon	1st Assistant	DOB	Age at Tx	Weight at Tx	Other Pathway Specific Details
1	Transplant
2	Transplant
3	Transplant
4	Transplant
5	Transplant
6	Transplant
7	Transplant
8	Transplant
9	Transplant
10	Transplant
11	Transplant
12	Transplant
13	Transplant
14	Transplant
15	Transplant
16	Transplant
17	Transplant
18	Transplant
19	Transplant
20	Transplant
21	Transplant
22	Transplant
23	Transplant
24	Transplant
25	Transplant
26	Transplant
27	Transplant
28	Transplant
29	Transplant

30	Transplant
31	Transplant
32	Transplant
33	Transplant
34	Transplant
35	Transplant
36	Transplant
37	Transplant
38	Transplant
39	Transplant
40	Transplant
41	Transplant
42	Transplant
43	Transplant
44	Transplant
45	Transplant
46	Transplant
47	Transplant
48	Transplant
49	Transplant
50	Transplant
51	Transplant
52	Transplant

Primary Surgeon Log: Procurements

Name of Surgeon:

Organ:

Hospital: Time Frame at Hospital: Signature Name: Signature Title:

Signature: Date:

						Pediatric Only
#	Type of Procedure	Procurement Date	Patient Identifier	Primary/Co Surgeon	1st Assistant	DOB	Age at Tx	Weight at Tx	LD/DD	Open/Lap	Other Pathway Specific Details
1	Procurement
2	Procurement
3	Procurement
4	Procurement
5	Procurement
6	Procurement
7	Procurement
8	Procurement
9	Procurement
10	Procurement
11	Procurement
12	Procurement
13	Procurement
14	Procurement
15	Procurement
16	Procurement
17	Procurement
18	Procurement
19	Procurement
20	Procurement
21	Procurement
22	Procurement
23	Procurement
24	Procurement
25	Procurement

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 1.17 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 Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

Primary Physician Log: Recipient

Name of Physician:

Organ:

Hospital: Time Frame at Hospital:

Signature Name:

Signature Title:

Signature: Date:

							Pediatric Only
#	Physician Involvement	Transplant Date	Patient Identifier	Pre-Operative Patient Care	Newly Transplanted Patient Care	Followed Patient for months	DOB	Age at Tx	Weight at Tx	Other Pathway Specific Details
1	Recipient Care
2	Recipient Care
3	Recipient Care
4	Recipient Care
5	Recipient Care
6	Recipient Care
7	Recipient Care
8	Recipient Care
9	Recipient Care
10	Recipient Care
11	Recipient Care
12	Recipient Care
13	Recipient Care
14	Recipient Care
15	Recipient Care
16	Recipient Care
17	Recipient Care
18	Recipient Care
19	Recipient Care
20	Recipient Care
21	Recipient Care
22	Recipient Care
23	Recipient Care
24	Recipient Care
25	Recipient Care
26	Recipient Care
27	Recipient Care
28	Recipient Care
29	Recipient Care
30	Recipient Care
31	Recipient Care
32	Recipient Care
33	Recipient Care
34	Recipient Care
35	Recipient Care
36	Recipient Care

37	Recipient Care
38	Recipient Care
39	Recipient Care
40	Recipient Care
41	Recipient Care
42	Recipient Care
43	Recipient Care
44	Recipient Care
45	Recipient Care
46	Recipient Care
47	Recipient Care
48	Recipient Care
49	Recipient Care
50	Recipient Care

Primary Physician Log: Observations

Name of Physician:

Organ: Hospital:

Time Frame at Hospital: Signature Name:

Signature Title:

Signature: Date:

#	Physician Involvement	Procurement Date	Donor ID	LD/DD
1	Procurement Observation
2	Procurement Observation
3	Procurement Observation

					Pediatric Only
#	Physician Involvement	Transplant Date	Patient Identifier	LD/DD	Age at Tx
1	Transplant Observation
2	Transplant Observation
3	Transplant Observation

Primary Physician Log: Evaluation

Name of Physician:

Organ: Hospital:

Time Frame at Hospital:

Signature Name:

Signature Title:

Signature: Date:

#	Physician Involvement	Evaluation Date	Patient Identifier	Recipient/ Living Donor	Other Pathway Specific Details
1	Evaluation
2	Evaluation
3	Evaluation
4	Evaluation
5	Evaluation
6	Evaluation
7	Evaluation
8	Evaluation
9	Evaluation
10	Evaluation
11	Evaluation
12	Evaluation
13	Evaluation
14	Evaluation
15	Evaluation
16	Evaluation
17	Evaluation
18	Evaluation
19	Evaluation
20	Evaluation

21	Evaluation
22	Evaluation
23	Evaluation
24	Evaluation
25	Evaluation
26	Evaluation
27	Evaluation
28	Evaluation
29	Evaluation
30	Evaluation
31	Evaluation
32	Evaluation
33	Evaluation
34	Evaluation
35	Evaluation
36	Evaluation
37	Evaluation

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 1.17 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 Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

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