OPTN Membership Application for Heart Transplant Program

Organ Procurement and Transplantation Network Application Form

Documents and Forms

Document Name Document Type
Form 6 B OPTN Membership Application for Heart Transplant Program Form and Instruction
6 B OPTN Membership Application_Surgeon or Physician Log OPTN Membership Application Surgeon or Physician Log.docx Form and Instruction
6 B OPTN Membership Application_Surgeon or Physician Log OPTN Membership Application Surgeon or Physician Log.docx Form and Instruction
6 OPTN Membership Application for Heart Transplant Program 09182023 - 06_OPTN Membership Application for Heart Transplant Programs - REDLINE.docx Form and Instruction
6 OPTN Membership Application for Heart Transplant Program 09182023 - 06_OPTN Membership Application for Heart Transplant Programs - REDLINE.docx Form and Instruction
6 06_OPTN Membership Application for Heart Transplant Prog 06_OPTN Membership Application for Heart Transplant Programs CLEAN 10072024.docx Form and Instruction
6 06_OPTN Membership Application for Heart Transplant Prog 06_OPTN Membership Application for Heart Transplant Programs CLEAN 10072024.docx Form and Instruction
6 06_OPTN Membership Application for Heart Transplant Prog 06_OPTN Membership Application for Heart Transplant Programs REDLINE 10072024.docx Form and Instruction
6 06_OPTN Membership Application for Heart Transplant Prog 06_OPTN Membership Application for Heart Transplant Programs REDLINE 10072024.docx Form and Instruction

Information Collection (IC) Details

IC Title:	OPTN Membership Application for Heart Transplant Program	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	6 B	OPTN Membership Application_Surgeon or Physician Log	OPTN Membership Application Surgeon or Physician Log.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6	OPTN Membership Application for Heart Transplant Programs	09182023 - 06_OPTN Membership Application for Heart Transplant Programs - REDLINE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6	06_OPTN Membership Application for Heart Transplant Programs CLEAN 10072024	06_OPTN Membership Application for Heart Transplant Programs CLEAN 10072024.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6	06_OPTN Membership Application for Heart Transplant Programs REDLINE 10072024	06_OPTN Membership Application for Heart Transplant Programs REDLINE 10072024.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 145	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	49	49
Annual IC Time Burden (Hours)	1,005	1,005
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.