Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Adult Heart Candidate Listing Registration Modified 5441 4516 0 Instruction
Form 80
Adult Heart and HeartLung Status 1 Criteria 1 Extension Justification Form Medical Urgency Data Modified 130 69 0 Form 130
Instruction
Adult Heart and HeartLung Status 1 Exception Extension Justification Form Medical Urgency Data Modified 164 54 0 Instruction
Form 129
Adult Heart and HeartLung Status 1 Initial Justification Form Medical Urgency Data Modified 1240 719 0 Form 128
Instruction
Adult Heart and HeartLung Status 1-6 Justification Form Demographic Data Modified 24074 7704 0 Form 126
Instruction
Adult Heart and HeartLung Status 1-6 Justification Form Risk Stratification Data Modified 24074 17333 0 Instruction
Form 127
Adult Heart and HeartLung Status 2 Criteria 1 Extension Justification Form Medical Urgency Data Modified 1 1 0 Instruction
Form 133
Adult Heart and HeartLung Status 2 Criteria 4 Extension Justification Form Medical Urgency Data Modified 825 520 0 Form 134
Instruction
Adult Heart and HeartLung Status 2 Criteria 5 Extension Justification Form Medical Urgency Data Modified 279 167 0 Instruction
Form 135
Adult Heart and HeartLung Status 2 Exception Extension Justification Form Medical Urgency Data Modified 2979 983 0 Form 132
Instruction
Adult Heart and HeartLung Status 2 Initial Justification Form Medical Urgency Data Modified 4267 3414 0 Form 131
Other-Redline
Adult Heart and HeartLung Status 3 Criteria 2 Extension Justification Form Medical Urgency Data Modified 80 26 0 Form 138
Instruction
Adult Heart and HeartLung Status 3 Criteria 5 Extension Justification Form Medical Urgency Data Modified 6 3 0 Instruction
Form 139
Adult Heart and HeartLung Status 3 Exception Extension Justification Form Medical Urgency Data Modified 1118 369 0 Instruction
Form 137
Adult Heart and HeartLung Status 3 Initial Justification Form Medical Urgency Data Modified 1676 1056 0 Form 136
Instruction
Adult Heart and HeartLung Status 4 Criteria 2 Extension Justification Form Medical Urgency Data Modified 116 46 0 Form 142
Instruction
Adult Heart and HeartLung Status 4 Exception Extension Justification Form Medical Urgency Data Modified 323 81 0 Instruction
Form 141
Adult Heart and HeartLung Status 4 Initial Justification Form Medical Urgency Data Modified 3488 1744 0 Form 140
Instruction
Adult HeartLung Candidate Listing Registration Modified 72 61 0 Form 82
Instruction
Other-Redline
Adult Intestine Candidate Listing Registration Modified 77 29 0 Instruction
Form 78
Adult Kidney Candidate Listing Registration Modified 52880 27497 0 Form 68
Instruction
Adult Kidney Pancreas Candidate Listing Registration Modified 1692 626 0 Instruction
Form 70
Adult Liver Candidate Listing Registration Modified 15458 4947 0 Instruction
Form 76
Adult Liver Status 1A Initial Justification and Extension Form Modified 307 175 0 Instruction
Form 105
Adult Lung Candidate Listing Registration Modified 3909 3948 0 Form 84
Other-Redline
Instruction
Adult Pancreas Candidate Listing Registration Modified 1939 737 0 Instruction
Form 72
Adult Pancreas Islet Listing Registration Modified 80 30 0 Instruction
Form 74
Adult and Pediatric Lung and HeartLung Goal Exception Form Modified 416 312 0 Instruction
Form 143
Candidate Registration Listing Removal Modified 76718 13809 0 Form 86
Instruction
Death Notification Registration Removed 0 0 0 Instruction
Form 66
Other-Redline
Deceased Donor Death Referral Removed 0 0 0 Instruction
Form 67
Other-Redline
Deceased Donor Registration (DDR) Modified 24882 11943 0 Form 1
Other-Redline
Instruction
Discrepant HLA Typings Reporting Form Modified 174 900 0 Form 149
Other-Redline
Instruction
Disease Transmission Event Modified 906 543 0 Instruction
Form 57
Other-Redline
Donor Histocompatibility Form Modified 24463 3669 0 Instruction
Form 4
Donor Hospital Registration Modified 4 0 0 Instruction
Form 65
Donor Organ Disposition Modified 24963 4244 0 Instruction
Form 66
Other-Redline
Extra Vessels Reporting Form Modified 14879 446 0 Instruction
Form 147
Heart Post-Transplant Malignancy Form Modified 2172 1955 0 Instruction
Form 11
Heart Transplant Candidate Registration (TCR) Modified 6090 5481 0 Instruction
Form 6
Other-Redline
Heart Transplant Recipient Follow Up (6 months) Modified 4248 1699 0 Instruction
Form 8
Other-Redline
Heart Transplant Recipient Follow Up 1-5 Year Modified 18270 16443 0 Instruction
Form 9
Other-Redline
Heart Transplant Recipient Follow Up Post 5 Year Modified 30196 15098 0 Instruction
Form 10
Other-Redline
Heart Transplant Recipient Registration (TRR) Modified 4586 8989 0 Instruction
Form 7
Other-Redline
Heart/Lung Post Transplant Malignancy (PTM) Form Modified 15 6 0 Instruction
Form 23
Heart/Lung Recipient Registration Modified 60 125 0 Instruction
Form 19
Other-Redline
Heart/Lung Transplant Candidate Registration (TCR) Modified 77 90 0 Instruction
Form 18
Other-Redline
Heart/Lung Transplant Recipient Follow Up 1-5 Year (TRF) Modified 202 222 0 Instruction
Form 21
Other-Redline
Heart/Lung Transplant Recipient Follow Up 6 Month (TRF) Modified 56 45 0 Instruction
Form 20
Other-Redline
Heart/Lung Transplant Recipient Follow Up Post 5 Year (TRF) Modified 273 164 0 Instruction
Form 22
Other-Redline
Initial Donor Registration Modified 24963 118574 0 Form 62
Other-Redline
Instruction
Interim Event Reporting Form Modified 22201 1332 0 Form 150
Instruction
Intestinal Waiting Time Reinstatement Form Modified 1 0 0 Form 102
Instruction
Intestine Post Transplant Malignancy (PTM) Form Modified 6 6 0 Instruction
Form 34
Intestine Transplant Candidate Registration (TCR) Modified 115 149 0 Instruction
Form 30
Other-Redline
Intestine Transplant Recipient Follow Up 6 Month -5 Year (TRF) Modified 396 594 0 Instruction
Form 32
Other-Redline
Intestine Transplant Recipient Follow Up Post 5 Year (TRF) Modified 890 356 0 Instruction
Form 33
Other-Redline
Intestine Transplant Recipient Registration (TRR) Modified 88 159 0 Instruction
Form 31
Other-Redline
Kidney Minimum Acceptance Criteria Modified 223 67 0 Form 104
Instruction
Kidney Paired Donation Candidate Registration Modified 62 16 0 Instruction
Form 54
Other-redline
Kidney Paired Donation Donor Registration Modified 115 124 0 Instruction
Form 55
Other-redline
Kidney Paired Donation Match Offer Management Modified 133 89 0 Instruction
Form 56
Kidney Post Transplant Malignancy (PTM) Form Modified 7324 5859 0 Instruction
Form 39
Kidney Transplant Candidate Registration (TCR) Modified 52393 41914 0 Instruction
Form 35
Other-Redline
Kidney Transplant Recipient Follow Up 6 Month -5 Year (TRF) Modified 141664 127497 0 Instruction
Form 37
Other-Redline
Kidney Transplant Recipient Follow Up Post 5 Year (TRF) Modified 143334 71667 0 Instruction
Form 38
Other-Redline
Kidney Transplant Recipient Registration (TRR) Modified 27594 33113 0 Instruction
Form 36
Other-Redline
Kidney/Pancreas Post Transplant Malignancy (PTM) Form Modified 295 118 0 Instruction
Form 49
Kidney/Pancreas Transplant Candidate Registration (TCR) Modified 1695 1017 0 Instruction
Form 45
Other-Redline
Kidney/Pancreas Transplant Recipient Follow Up 6 Month -5 Year (TRF) Modified 4515 2257 0 Instruction
Form 47
Other-Redline
Kidney/Pancreas Transplant Recipient Follow Up Post 5 Year (TRF) Modified 8660 5196 0 Instruction
Form 48
Other-redline
Kidney/Pancreas Transplant Recipient Registration (TRR) Modified 805 966 0 Instruction
Form 46
Other-Redline
Liver Cholangiocarcinoma (CCA) Initial MELD/PELD Score Exception Form Modified 120 51 0 Form 108
Instruction
Liver Cholangiocarcinoma (CCA) MELD/PELD Score Exception Extension Form Modified 96 31 0 Instruction
Form 109
Liver Cystic Fibrosis (CF) Initial MELD/PELD Score Exception and Extension Form Modified 12 4 0 Form 110
Instruction
Liver Familial Amyloid Polyneuropathy (FAP) Initial MELD/PELD Score Exception Form Modified 0 0 0 Instruction
Form 111
Liver Familial Amyloid Polyneuropathy (FAP) MELD/PELD Score Exception Extension Form Modified 1 0 0 Form 112
Instruction
Liver Hepatic Artery Thrombosis (HAT) Initial MELD/PELD Score Exception and Extension Form Modified 79 28 0 Instruction
Form 113
Liver Hepatocellular Carcinoma (HCC) Initial MELD/PELD Score Exception Form Modified 3194 1501 0 Form 114
Instruction
Liver Hepatocellular Carcinoma (HCC) MELD/PELD Score Exception Extension Form Modified 4153 1454 0 Instruction
Form 115
Liver Hepatopulmonary Syndrome (HPS) Initial MELD/PELD Score Exception Form Modified 204 65 0 Form 116
Instruction
Liver Hepatopulmonary Syndrome (HPS) MELD/PELD Score Exception Extension Form Modified 117 29 0 Instruction
Form 117
Liver Metabolic Disease Initial MELD/PELD Score Exception and Extension Form Modified 121 34 0 Form 118
Instruction
Liver Other Diagnosis Initial MELD/PELD Score Exception and Extension Form Modified 2064 722 0 Form 122
Instruction
Liver Portopulmonary Hypertension Initial MELD/PELD Score Exception Form Modified 75 31 0 Instruction
Form 119
Liver Portopulmonary Hypertension MELD/PELD Score Exception Extension Form Modified 55 18 0 Form 120
Instruction
Liver Post Transplant Malignancy (PTM) Form Modified 3915 3132 0 Instruction
Form 29
Liver Primary Hyperoxaluria Initial MELD/PELD Score Exception and Extension Form Modified 14 5 0 Instruction
Form 121
Liver Recipient Explant Pathology Form Modified 1125 675 0 Instruction
Form 28
Other-Redline
Liver Transplant Candidate Registration (TCR) Modified 16197 12958 0 Instruction
Form 24
Other-Redline
Liver Transplant Recipient Follow Up 6 Month -5 Year (TRF) Modified 55368 55368 0 Instruction
Form 26
Other-Redline
Liver Transplant Recipient Follow Up Post 5 Year (TRF) Modified 67218 33609 0 Instruction
Form 27
Other-Redline
Liver Transplant Recipient Registration (TRR) Modified 12344 14812 0 Instruction
Form 25
Other-Redline
Living Donor Event Modified 50 28 0 Instruction
Form 58
Living Donor Feedback Form Modified 8122 1056 0 Form 146
Instruction
Living Donor Follow-up (LDF) Modified 20969 31873 0 Form 3
Other-Redline
Instruction
Living Donor Registration (LDR) Modified 6573 14461 0 Instruction
Form 2
Other-Redline
Lung - Post Transplant Malignancy (PTM) Form Modified 1750 700 0 Instruction
Form 17
Lung Transplant Candidate Registration (TCR) Modified 3947 3750 0 Instruction
Form 12
Other-Redline
Lung Transplant Recipient Follow Up 1-5 Year (TRF) Modified 11373 12510 0 Instruction
Form 15
Other-Redline
Lung Transplant Recipient Follow Up 6 Month (TRF) Modified 3183 1592 0 Instruction
Form 14
Other-Redline
Lung Transplant Recipient Follow Up Post 5 Year (TRF) Modified 12494 7496 0 Instruction
Form 16
Other-Redline
Lung Transplant Recipient Registration (TRR) Modified 3491 3980 0 Instruction
Form 13
Other-Redline
Non-US Transplants Reporting Form Modified 0 0 0 Form 148
Instruction
OPO Notification Limit Administration Modified 9 1 0 Instruction
Form 63
OPTN Pancreas Waiting Time Reinstatement Form Modified 5 1 0 Instruction
Form 101
OPTN Renal Waiting Time Reinstatement Form Modified 309 83 0 Form 100
Instruction
OPTN Waiting Time Modification Form Modified 5956 1310 0 Instruction
Form 99
OPTN Waiting Time Transfer Form Modified 1335 307 0 Form 98
Instruction
Organ Export Verification Form Modified 16 0 0 Form 97
Instruction
Organ Labeling and Packaging System Modified 16966 3054 0 Instruction
Form 52
Organ Tracking and Validating System Modified 5716 457 0 Instruction
Form 53
Pancreas Post Transplant Malignancy (PTM) Form Modified 91 55 0 Instruction
Form 44
Pancreas Transplant Candidate Registration (TCR) Modified 279 168 0 Instruction
Form 40
Other-Redline
Pancreas Transplant Recipient Follow Up 6 Month -5 Year (TRF) Modified 533 267 0 Instruction
Form 42
Other-Redline
Pancreas Transplant Recipient Follow Up Post 5 Year (TRF) Modified 1995 998 0 Instruction
Form 43
Other-redline
Pancreas Transplant Recipient Registration (TRR) Modified 107 128 0 Instruction
Form 41
Other-Redline
Patient Safety Contact Management Form New 12913 1808 0 Form 151
Instruction
Patient Transfer Form New 3853 1503 0 Form 152
Instruction
Pediatric Heart Candidate Listing Registration Modified 649 376 0 Instruction
Form 81
Pediatric Heart and HeartLung Status 1A Extension and Appeal Justification Forms Modified 4635 2178 0 Form 124
Instruction
Pediatric Heart and HeartLung Status 1A Initial Justification Form Modified 980 510 0 Instruction
Form 123
Pediatric Heart and HeartLung Status 1B Initial Justification Form Modified 444 187 0 Instruction
Form 125
Pediatric HeartLung Candidate Listing Registration Modified 5 5 0 Form 83
Other-Redline
Instruction
Pediatric Intestine Candidate Listing Registration Modified 38 16 0 Form 79
Instruction
Pediatric Kidney Candidate Listing Registration Modified 1201 564 0 Form 69
Instruction
Pediatric Kidney Pancreas Candidate Listing Registration Modified 3 1 0 Form 71
Instruction
Pediatric Liver Candidate Listing Registration Modified 738 295 0 Form 77
Instruction
Pediatric Liver Status 1A Initial Justification and Extension Form Modified 177 101 0 Form 106
Instruction
Pediatric Liver Status 1B Initial Justification and Extension Form Modified 419 197 0 Instruction
Form 107
Pediatric Lung Candidate Listing Registration Modified 38 32 0 Instruction
Form 85
Pediatric Lung Priority 1 Status Justification Form Modified 24 8 0 Form 144
Instruction
Pediatric Pancreas Candidate Listing Registration Modified 35 13 0 Form 73
Instruction
Pediatric Pancreas Islet Listing Registration Modified 0 0 0 Form 75
Instruction
Potential Disease Transmission Report Modified 813 1032 0 Instruction
Form 60
Potential Transplant Recipient Modified 1631665 81583 0 Instruction
Form 64
Other-Redline
Prior Living Donor Priority Modified 95 26 0 Instruction
Form 103
Recipient Histocompatibility Form Modified 44362 14196 0 Form 5
Other-Redline
Instruction
Request to Unlock Form Modified 69179 1384 0 Instruction
Form 61
Review Board Voter Form Modified 6212 1429 0 Instruction
Form 145
Safety Situation Modified 589 141 0 Instruction
Form 59
Other-Redline
Transplant Center Contact Management Modified 216728 13004 0 Instruction
Form 67
VCA Abdominal Wall Candidate Listing Registration Modified 0 0 0 Instruction
Form 87
VCA External Male Genitalia Candidate Listing Registration Modified 0 0 0 Form 88
Instruction
VCA Head and Neck Candidate Listing Registration Modified 1 0 0 Form 89
Instruction
VCA Lower Limb Candidate Listing Registration Modified 0 0 0 Instruction
Form 90
VCA Musculoskeletal Composite Graft Segment Candidate Listing Registration Modified 0 0 0 Form 91
Instruction
VCA Other Genitourinary Organ Candidate Listing Registration Modified 1 0 0 Instruction
Form 92
VCA Spleen Candidate Listing Registration Modified 0 0 0 Form 93
Instruction
VCA Transplant Candidate Registration (TCR) Removed 0 0 0 Instruction
Form 50
Other-Redline
VCA Transplant Recipient Follow Up (TRF) Modified 67 88 0 Instruction
Form 51
Other-redline
VCA Transplant Recipient Registration (TRR) Modified 9 12 0 Instruction
Form 50
Other-Redline
VCA Upper Limb Candidate Listing Registration Modified 0 0 0 Instruction
Form 94
VCA Uterus Candidate Listing Registration Modified 11 4 0 Form 95
Instruction
VCA Vascularized Gland Candidate Listing Registration Modified 0 0 0 Instruction
Form 96
Total burden requested under this ICR: 3085442 903603 0  
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