OPTN Pancreas Waiting Time Reinstatement Form

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

OPTN Pancreas Time Reinstatement Form

This form is required to reinstate waiting time without interruption in instances of immediate and permanent non-function of a transplanted pancreas. The patient should be relisted on the waiting list and this form must be printed, completed, signed by the transplant physician/surgeon, and submitted to UNOS with required documentation of the failed transplant. Policy includes the definition for immediate and permanent non-function of the pancreas.

OPTN Pancreas Waiting Time

CANDIDATE NAME: Enter the candidate’s name.

CANDIDATE HIC #/SSN: Enter the candidate’s HIC number or SSN.

TRANSPLANT PROGRAM NAME/CODE: Enter the name/code of the transplant hospital.

DATE OF TRANSPLANT: Enter the date the transplant took place.

Pancreas waiting time will be reinstated for recipients when immediate and permanent non-function of a transplanted pancreas occurs. Requests will not be considered until the following is completed by the requesting transplant program:

• Patient has been re-listed

Please indicate which option below is being used for the request for reinstatement of waiting time and include the required documentation.

OPTION 1: Removal of the Transplanted Pancreas

Date of graft failure (must be within 14 days of transplant)

Operative report for removal of transplanted pancreas

OPTION 2: Statement of Intent

Date of graft failure (must be within 14 days of transplant)

I intend to remove the previously transplanted pancreas on the above recipient within 14 days of transplant AND there is documented, radiographic evidence indicating that the transplanted pancreas has failed. The transplant program (identified above) will maintain this documentation and will submit this documentation to the OPTN Contractor upon request.

TRANSPLANT PHYSICIAN/SURGEON SIGNATURE: Signature of the requesting transplant physical or surgeon.

DATE: The date the form was signed.

TRANSPLANT PHYSICIAN/SURGEON NAME (Please print or type): Print or type the name of the requesting transplant physical or surgeon.

Transplant Program Contact Name: Enter the name of the appropriate contact person at the transplant program.

Transplant Program Contact Email: The contact’s email address.

Transplant Program Contact Phone Number: The contact’s phone number.

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 0915-0157 and it is valid until XX/XX/202X. 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 0.27 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.   

OPTN Restricted

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Living Donor Registration LDR Instructions
Author	Tara Taylor
File Modified	0000-00-00
File Created	2025-07-03