OPTN Membership Application for Kidney Transplant Programs

Organ Procurement and Transplantation Network Application Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0184 can be found here:

Documents and Forms

Document Name Document Type
Form 3 OPTN Membership Application for Kidney Transplant Programs Form and Instruction
3 Membership_Kidney_LDKidney Form.docx Membership_Kidney_LDKidney Form.docx Form and Instruction
3B Membership_SurgeonOrPhysicianLog Form.docx Membership_SurgeonOrPhysicianLog Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	OPTN Membership Application for Kidney Transplant Programs	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Membership_Kidney_LDKidney Form.docx	Membership_Kidney_LDKidney Form.docx		Yes	No	Fillable Fileable
Form and Instruction	3B	Membership_SurgeonOrPhysicianLog Form.docx	Membership_SurgeonOrPhysicianLog Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 189	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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	378	142	236
Annual IC Time Burden (Hours)	1,134	190	944
Annual IC Cost Burden (Dollars)	0	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.