50 VCA Transplant Candidate Registration_Form.xlsx

TCR - VCA - Adult/Ped
Fields to be completed by members
Form Section	Field Label	Notes
Provider Information	Candidate Center:	Display Only - Cascades from Waitlist
Candidate Information	Organ Registered:	Display Only - Cascades from Waitlist
Candidate Information	Listing Date:	Display Only - Cascades from Waitlist
Candidate Information	Last Name:	Display Only - Cascades from Waitlist
Candidate Information	First Name:	Display Only - Cascades from Waitlist
Candidate Information	Middle Initial:	Display Only - Cascades from Waitlist
Candidate Information	SSN:	Display Only - Cascades from Waitlist
Candidate Information	Date of Birth:	Display Only - Cascades from Waitlist
Candidate Information	Gender:	Display Only - Cascades from Waitlist
Candidate Information	Ethnicity/Race:	Display Only - Cascades from Waitlist
Clinical Information	Height (in)	Display Only - Cascades from Waitlist
Clinical Information	Weight (lbs.)	Display Only - Cascades from Waitlist
Clinical Information	ABO Blood Group:	Display Only - Cascades from Waitlist
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 0.7 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.