Form 105 Intestinal Waiting Time Reinstatement Form

Intestinal Waiting Time Reinstatement Form
Fields to be completed by members
Form Section	Field Label	Notes
OPTN Intestinal Waiting Time	CANDIDATE NAME
OPTN Intestinal Waiting Time	CANDIDATE HIC #/SSN
OPTN Intestinal Waiting Time	TRANSPLANT PROGRAM NAME/CODE
OPTN Intestinal Waiting Time	DATE OF TRANSPLANT
OPTN Intestinal Waiting Time	Patient has been re-listed
OPTN Intestinal Waiting Time	Operative report attached for the removal of the transplanted intestine
OPTN Intestinal Waiting Time	Date of removal (must be within 7 days of transplant)
OPTN Intestinal Waiting Time	TRANSPLANT PHYSICIAN/SURGEON SIGNATURE
OPTN Intestinal Waiting Time	DATE
OPTN Intestinal Waiting Time	TRANSPLANT PHYSICIAL/SURGEON NAME (Please print or type)
OPTN Intestinal Waiting Time	Transplant Program Contact Name
OPTN Intestinal Waiting Time	Transplant Program Contact Email
OPTN Intestinal Waiting Time	Transplant Program Contact Phone Number
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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.