| Adult HeartLung Candidate Listing Registration |
| Fields to be completed by members |
|
|
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| Form Section |
Field Label |
Notes |
| Add new candidate registration |
Transplant Hospital |
Display Only - Cascade from database |
| Add new candidate registration |
Organ |
|
| Candidate Add |
Center |
Display Only - Cascade from database |
| Candidate Add |
Organ |
Display Only - Cascade from database |
| Candidate Add |
SSN |
|
| Candidate Add |
Confirm SSN |
|
| Candidate Add |
Age Group |
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| Provider Information |
Transplant Hospital |
Display Only - Cascade from database |
| Provider Information |
24 Hour Contact Phone Number |
|
| Demographic Information |
SSN |
|
| Demographic Information |
Confirm SSN |
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| Demographic Information |
Last Name |
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| Demographic Information |
First Name |
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| Demographic Information |
MI |
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| Demographic Information |
Date of birth |
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| Demographic Information |
Confirm date of birth |
|
| Demographic Information |
Birth sex |
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| Demographic Information |
Center Patient ID |
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| Demographic Information |
State of Permanent Residence |
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| Demographic Information |
Permanent ZIP Code |
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| Demographic Information |
Ethnicity |
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| Demographic Information |
Race |
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| Clinical Information |
ABO |
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| Clinical Information |
Accept an Intended Blood Group Incompatible Organ? |
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| Clinical Information |
Height (ft) |
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| Clinical Information |
Height (in) |
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| Clinical Information |
Height (cm) |
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| Clinical Information |
Date |
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| Clinical Information |
Weight (lbs) |
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| Clinical Information |
Weight (kg) |
|
| Clinical Information |
Date |
|
| Clinical Information |
BMI |
Display Only - Calculated |
| HLA CLASS I |
A |
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| HLA CLASS I |
A |
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| HLA CLASS I |
B |
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| HLA CLASS I |
B |
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| HLA CLASS I |
BW4 |
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| HLA CLASS I |
BW6 |
|
| HLA CLASS I |
C |
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| HLA CLASS I |
C |
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| HLA CLASS II |
DR |
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| HLA CLASS II |
DR |
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| HLA CLASS II |
DR51 |
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| HLA CLASS II |
DR51 |
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| HLA CLASS II |
DR52 |
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| HLA CLASS II |
DR52 |
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| HLA CLASS II |
DR53 |
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| HLA CLASS II |
DR53 |
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| HLA CLASS II |
DQB1 |
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| HLA CLASS II |
DQB1 |
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| HLA CLASS II |
DQA1 |
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| HLA CLASS II |
DQA1 |
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| HLA CLASS II |
DPB1 |
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| HLA CLASS II |
DPB1 |
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| HLA CLASS II |
DPA1 |
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| HLA CLASS II |
DPA1 |
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| Confirm HLA CLASS I |
A |
|
| Confirm HLA CLASS I |
A |
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| Confirm HLA CLASS I |
B |
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| Confirm HLA CLASS I |
B |
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| Confirm HLA CLASS I |
BW4 |
|
| Confirm HLA CLASS I |
BW6 |
|
| Confirm HLA CLASS I |
C |
|
| Confirm HLA CLASS I |
C |
|
| Confirm HLA CLASS II |
DR |
|
| Confirm HLA CLASS II |
DR |
|
| Confirm HLA CLASS II |
DR51 |
|
| Confirm HLA CLASS II |
DR51 |
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| Confirm HLA CLASS II |
DR52 |
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| Confirm HLA CLASS II |
DR52 |
|
| Confirm HLA CLASS II |
DR53 |
|
| Confirm HLA CLASS II |
DR53 |
|
| Confirm HLA CLASS II |
DQB1 |
|
| Confirm HLA CLASS II |
DQB1 |
|
| Confirm HLA CLASS II |
DQA1 |
|
| Confirm HLA CLASS II |
DQA1 |
|
| Confirm HLA CLASS II |
DPB1 |
|
| Confirm HLA CLASS II |
DPB1 |
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| Confirm HLA CLASS II |
DPA1 |
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| Confirm HLA CLASS II |
DPA1 |
|
| Organ Information |
Candidate Medical Urgency Status |
|
| Organ Information |
Inactive Reason |
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| Organ Information |
Heart Diagnosis Code |
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| Organ Information |
Lung Diagnosis Code |
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| Organ Information |
Indicate reason for change in diagnosis |
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| Organ Information |
Other specify |
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| Organ Information |
Functional Status |
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| Organ Information |
Eval Date |
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| Organ Information |
Diabetes |
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| Organ Information |
Eval Date |
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| Organ Information |
Assisted Ventilation |
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| Organ Information |
Eval Date |
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| Organ Information |
Requires Supplemental O2 |
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| Organ Information |
Eval Date |
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| Organ Information |
On high flow nasal cannula? |
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| Organ Information |
Amount L/min |
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| Organ Information |
Amount Percent |
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| Organ Information |
Pulmonary Function Test Date |
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| Organ Information |
Actual Forced Vital Capacity (FVC) |
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| Organ Information |
Percent Predicted FVC |
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| Organ Information |
Pre Bronchodilator Actual FEV1 |
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| Organ Information |
Pre Bronchodilator Percent Predicted FEV1 |
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| Organ Information |
Post Bronchodilator Actual FEV1 |
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| Organ Information |
Post Bronchodilator Percent Predicted FEV1 |
|
| Organ Information |
Six Minute Walk Distance |
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| Organ Information |
Test Date |
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| Organ Information |
Most Recent Heart Catheterization Date |
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| Organ Information |
Pulmonary Artery Systolic Pressure |
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| Organ Information |
Pulmonary Artery Diastolic Pressure |
|
| Organ Information |
Mean Pulmonary Artery Pressure |
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| Organ Information |
Pulmonary Capillary Wedge Mean |
|
| Organ Information |
Cardiac Output (CO) |
|
| Organ Information |
Cardiac Index (CI) |
|
| Organ Information |
Central Venous Pressure (CVP) |
|
| Organ Information |
Test Date |
|
| Organ Information |
Hgb/Hct Test Date |
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| Organ Information |
Hemoglobin (Hgb) |
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| Organ Information |
Hematocrit (Hct) |
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| Organ Information - Blood Gas Information |
Date |
|
| Organ Information - Blood Gas Information |
Time |
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| Organ Information - Blood Gas Information |
Blood Gas Test Type |
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| Organ Information - Blood Gas Information |
pH |
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| Organ Information - Blood Gas Information |
PCO2 |
|
| Organ Information - Blood Gas Information |
PO2 |
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| Organ Information - Blood Gas Information |
Supplemental O2 at time of test? |
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| Organ Information - Blood Gas Information |
O2 Amount L/min |
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| Organ Information - Blood Gas Information |
O2 Amount Percent |
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| Organ Information - Blood Gas Information |
Date |
|
| Organ Information - Blood Gas Information |
Time |
|
| Organ Information - Blood Gas Information |
Blood Gas Test Type |
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| Organ Information - Blood Gas Information |
pH |
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| Organ Information - Blood Gas Information |
PCO2 |
|
| Organ Information - Blood Gas Information |
PO2 |
|
| Organ Information - Blood Gas Information |
Supplemental O2 at time of test? |
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| Organ Information - Blood Gas Information |
O2 Amount L/min |
|
| Organ Information - Blood Gas Information |
O2 Amount Percent |
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| Organ Information - Blood Gas Information |
Date |
|
| Organ Information - Blood Gas Information |
Time |
|
| Organ Information - Blood Gas Information |
Blood Gas Test Type |
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| Organ Information - Blood Gas Information |
pH |
|
| Organ Information - Blood Gas Information |
PCO2 |
|
| Organ Information - Blood Gas Information |
PO2 |
|
| Organ Information - Blood Gas Information |
Supplemental O2 at time of test? |
|
| Organ Information - Blood Gas Information |
O2 Amount L/min |
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| Organ Information - Blood Gas Information |
O2 Amount Percent |
|
| Organ Information - Serum Creatinine Information |
Date |
|
| Organ Information - Serum Creatinine Information |
Time |
|
| Organ Information - Serum Creatinine Information |
Serum Creatinine |
|
| Organ Information - Serum Creatinine Information |
Date |
|
| Organ Information - Serum Creatinine Information |
Time |
|
| Organ Information - Serum Creatinine Information |
Serum Creatinine |
|
| Organ Information - Serum Creatinine Information |
Date |
|
| Organ Information - Serum Creatinine Information |
Time |
|
| Organ Information - Serum Creatinine Information |
Serum Creatinine |
|
| Organ Information - Total Bilirubin Information |
Date |
|
| Organ Information - Total Bilirubin Information |
Time |
|
| Organ Information - Total Bilirubin Information |
Total Bilirubin |
|
| Organ Information - Total Bilirubin Information |
Date |
|
| Organ Information - Total Bilirubin Information |
Time |
|
| Organ Information - Total Bilirubin Information |
Total Bilirubin |
|
| Organ Information - Total Bilirubin Information |
Date |
|
| Organ Information - Total Bilirubin Information |
Time |
|
| Organ Information - Total Bilirubin Information |
Total Bilirubin |
|
| Organ Information |
Preliminary Crossmatch Required |
|
| Organ Information |
Number of previous Heart/Lung Transplants |
|
| Organ Information |
Is the candidate listed for a vascularized composite allograft (VCA)? |
|
| Additional Organs |
Check any additional organs the candidate may need. |
|
| Donor Characteristics |
Minimum acceptable donor age |
|
| Donor Characteristics |
Maximum acceptable donor age |
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| Donor Characteristics |
Minimum acceptable donor height |
|
| Donor Characteristics |
Maximum acceptable donor height |
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| Donor Characteristics |
Minimum acceptable donor weight |
|
| Donor Characteristics |
Maximum acceptable donor weight |
|
| Donor Characteristics |
Donor birth sex requirements |
|
| Donor Characteristics |
Accept DCD donor? |
|
| Medical and Social History |
Accept a donor with a history of coronary artery disease? |
|
| Medical and Social History |
Accept a donor with cigarette use > 20 packs years ever? |
|
| Infectious diseases |
Accept a Hepatitis B core antibody positive donor? |
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| Infectious diseases |
Accept an HBV NAT positive donor? |
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| Infectious diseases |
Accept an HCV antibody positive donor? |
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| Infectious diseases |
Accept an HCV NAT positive donor? |
|
| Recovery |
Maximum nautical miles the organ or recovery team will travel |
|
| Unacceptable Antigens |
A |
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| Unacceptable Antigens |
B |
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| Unacceptable Antigens |
BW |
|
| Unacceptable Antigens |
C |
|
| Unacceptable Antigens |
DR |
|
| Unacceptable Antigens |
DR51 |
|
| Unacceptable Antigens |
DR52 |
|
| Unacceptable Antigens |
DR53 |
|
| Unacceptable Antigens |
DQB1 |
|
| Unacceptable Antigens |
DQA1 |
|
| Unacceptable Antigens |
DPB1 - unacceptable antigens |
|
| Unacceptable Antigens |
DPB1 - unacceptable epitopes |
|
| Unacceptable Antigens |
DPA1 |
|
| Risk Stratification Data |
Total number of prior sternotomies |
|
| Risk Stratification Data |
Any prior history of stroke? |
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| Risk Stratification Data |
Any prior history of peripheral thromboembolic events? |
|
| Risk Stratification Data |
Number of hospitalizations for heart failure in last 12 months |
|
| Risk Stratification Data |
Is the candidate on a diuretic? |
|
| Risk Stratification Data |
Furosemide - Amount |
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| Risk Stratification Data |
Furosemide - IV/PO |
|
| Risk Stratification Data |
Torsemide - Amount |
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| Risk Stratification Data |
Torsemide - IV/PO |
|
| Risk Stratification Data |
Bumetanide - Amount |
|
| Risk Stratification Data |
Bumetanide - IV/PO |
|
| Risk Stratification Data |
Chlorothiazide - Amount |
|
| Risk Stratification Data |
Chlorothiazide - IV/PO |
|
| Risk Stratification Data |
Metolazone - Amount |
|
| Risk Stratification Data |
Metolazone - IV/PO |
|
| Risk Stratification Data |
Other diuretic - Name |
|
| Risk Stratification Data |
Other diuretic - Amount |
|
| Risk Stratification Data |
Other diuretic - IV/PO |
|
| Risk Stratification Data |
Is the candidate on vasoactive support? |
|
| Risk Stratification Data |
Dobutamine |
|
| Risk Stratification Data |
Dopamine |
|
| Risk Stratification Data |
Milrinone |
|
| Risk Stratification Data |
Epinephrine |
|
| Risk Stratification Data |
Norepinephrine |
|
| Risk Stratification Data |
Vasopressin |
|
| Risk Stratification Data |
Is the candidate on anti-arrhythmics? |
|
| Risk Stratification Data |
Is the candidate on pulmonary vasodilators? |
|
| Risk Stratification Data |
Pulmonary Vasodilators Specify |
|
| Risk Stratification Data |
Is the candidate on dialysis? |
|
| Risk Stratification Data |
Is the candidate on continuous invasive mechanical ventilation? |
|
| Risk Stratification Data |
Most Recent Cardiopulmonary Stress Test Date |
|
| Risk Stratification Data |
Peak O2 consumption |
|
| Risk Stratification Data |
Respiratory exchange ratio (RER) |
|
| Risk Stratification Data |
VE/VCO2 |
|
| Risk Stratification Data |
Most Recent Sensitization Data Date |
|
| Risk Stratification Data |
CPRA |
|
| Risk Stratification Data |
PRA typing method |
|
| Risk Stratification Data |
Other Specify |
|
| Risk Stratification Data |
MFI threshold |
|
| Risk Stratification Data |
Most Recent Hemodynamic Data Date |
|
| Risk Stratification Data |
Hemodynamic data obtained using |
|
| Risk Stratification Data |
Other Specify |
|
| Risk Stratification Data |
Hemodynamic values were obtained when candidate was on |
|
| Risk Stratification Data |
Systolic blood pressure |
|
| Risk Stratification Data |
Diastolic blood pressure |
|
| Risk Stratification Data |
Resting heart rate (on same date as hemodynamic test) |
|
| Risk Stratification Data |
Central venous pressure |
|
| Risk Stratification Data |
Pulmonary artery systolic pressure |
|
| Risk Stratification Data |
Pulmonary artery diastolic pressure |
|
| Risk Stratification Data |
Mean pulmonary arty pressure |
|
| Risk Stratification Data |
Value obtained for PCWP or LVEDP |
|
| Risk Stratification Data |
PCWP/LVEDP - Amount |
|
| Risk Stratification Data |
Cardiac output |
|
| Risk Stratification Data |
Cardiac index |
|
| Risk Stratification Data |
Mixed venous oxygen saturation (SvO2) |
|
| Risk Stratification Data |
Hemoglobin at time of SvO2 |
|
| Risk Stratification Data |
Most Recent Data for VAD patients |
|
| Risk Stratification Data |
LDH |
|
| Risk Stratification Data |
Test date |
|
| Risk Stratification Data |
Plasma free hemoglobin |
|
| Risk Stratification Data |
Test date |
|
| Risk Stratification Data |
Has the candidate experience hemoglobinuria? |
|
| Risk Stratification Data |
Most Recent Heart Failure Severity Data |
|
| Risk Stratification Data |
Serum sodium |
|
| Risk Stratification Data |
Test date |
|
| Risk Stratification Data |
Serum creatinine |
|
| Risk Stratification Data |
Test date |
|
| Risk Stratification Data |
BUN |
|
| Risk Stratification Data |
Test date |
|
| Risk Stratification Data |
Serum albumin |
|
| Risk Stratification Data |
Test date |
|
| Risk Stratification Data |
AST |
|
| Risk Stratification Data |
Test date |
|
| Risk Stratification Data |
Serum bilirubin |
|
| Risk Stratification Data |
Test date |
|
| Risk Stratification Data |
Arterial lactate |
|
| Risk Stratification Data |
Test date |
|
| Risk Stratification Data |
INR |
|
| Risk Stratification Data |
Test date |
|
| Risk Stratification Data |
Brain natriuretic peptide test performed |
|
| Risk Stratification Data |
BNP test type |
|
| Risk Stratification Data |
BNP/NT Pro BNP - Amount |
|
| Risk Stratification Data |
Test date |
|
| Justification Form Information |
Surgeon/Physician NPI |
|
| Justification Form Information |
Surgeon/Physician name |
|
| Justification Form Information |
Hospital Telephone Number |
|
| Justification Form Status 1 |
Is the candidate currently admitted to the listing transplant hospital? |
|
| Justification Form Status 1 |
Primary device |
|
| Justification Form Status 1 |
Device Brand |
|
| Justification Form Status 1 |
Other specify |
|
| Justification Form Status 1 |
Date of implant/initiation |
|
| Justification Form Status 1 |
Time of implant/initiation |
|
| Justification Form Status 1 |
Ventricle support |
|
| Justification Form Status 1 |
Secondary device |
|
| Justification Form Status 1 |
Device Brand |
|
| Justification Form Status 1 |
Other specify |
|
| Justification Form Status 1 |
Date of implant/initiation |
|
| Justification Form Status 1 |
Ventricle support |
|
| Justification Form Status 1 |
Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO) |
|
| Justification Form Status 1 |
Select one of the following |
|
| Justification Form Status 1 |
Was the candidate on inotropes at the time cardiac index was obtained? |
|
| Justification Form Status 1 |
Cardiac index |
|
| Justification Form Status 1 |
Test Date |
|
| Justification Form Status 1 |
Test Time |
|
| Justification Form Status 1 |
Pulmonary capillary wedge pressure |
|
| Justification Form Status 1 |
Test Date |
|
| Justification Form Status 1 |
Test Time |
|
| Justification Form Status 1 |
Systolic blood pressure |
|
| Justification Form Status 1 |
Test Date |
|
| Justification Form Status 1 |
Test Time |
|
| Justification Form Status 1 |
Date of administration of CPR |
|
| Justification Form Status 1 |
Test Time |
|
| Justification Form Status 1 |
Systolic blood pressure |
|
| Justification Form Status 1 |
Test Date |
|
| Justification Form Status 1 |
Test Time |
|
| Justification Form Status 1 |
Arterial lactate |
|
| Justification Form Status 1 |
Test Date |
|
| Justification Form Status 1 |
Test Time |
|
| Justification Form Status 1 |
Aspartate transaminase |
|
| Justification Form Status 1 |
Test Date |
|
| Justification Form Status 1 |
Test Time |
|
| Justification Form Status 1 |
Alanine transaminase |
|
| Justification Form Status 1 |
Test Date |
|
| Justification Form Status 1 |
Test Time |
|
| Justification Form Status 1 |
Non-dischargeable, surgically implanted, non-endovascular biventricular support device |
|
| Justification Form Status 1 |
Mechanical circulatory support device (MCSD) with life threatening ventricular arrhythmia |
|
| Justification Form Status 1 |
Select at least one of the following |
|
| Justification Form Status 1 |
Exception for status 1 |
|
| Justification Form Status 1 |
This exception request is specifically related to a device recall |
|
| Justification Form Status 1 |
Clinical Narrative |
|
| Justification Form Status 2 |
Primary device |
|
| Justification Form Status 2 |
Device Brand |
|
| Justification Form Status 2 |
Other specify |
|
| Justification Form Status 2 |
Date of implant/initiation |
|
| Justification Form Status 2 |
Time of implant/initiation |
|
| Justification Form Status 2 |
Ventricle support |
|
| Justification Form Status 2 |
Secondary device |
|
| Justification Form Status 2 |
Device Brand |
|
| Justification Form Status 2 |
Other specify |
|
| Justification Form Status 2 |
Date of implant/initiation |
|
| Justification Form Status 2 |
Ventricle support |
|
| Justification Form Status 2 |
Non-dischargeable, surgically implanted, non-endovascular left ventricular assist device (LVAD) |
|
| Justification Form Status 2 |
Total artificial heart (TAH), BiVAD, right ventricular assist device (RVAD), or ventricular assist device (VAD) for single ventricle patients |
|
| Justification Form Status 2 |
Mechanical circulatory support device (MCSD) with malfunction |
|
| Justification Form Status 2 |
Percutaneous endovascular mechanical circulatory support device |
|
| Justification Form Status 2 |
Select one of the following |
|
| Justification Form Status 2 |
Cardiac index |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Pulmonary capillary wedge pressure |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Systolic blood pressure |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Date of administration of CPR |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Systolic blood pressure |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Arterial lactate |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Aspartate transaminase |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Alanine transaminase |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Intra-aortic balloon pump (IABP) |
|
| Justification Form Status 2 |
Select one of the following |
|
| Justification Form Status 2 |
Cardiac index |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Pulmonary capillary wedge pressure |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Systolic blood pressure |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Date of administration of CPR |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Systolic blood pressure |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Arterial lactate |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Aspartate transaminase |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Alanine transaminase |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Was the candidate on inotropes at the time cardiac index was obtained? |
|
| Justification Form Status 2 |
Cardiac index |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Pulmonary capillary wedge pressure |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Systolic blood pressure |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Hemodynamic measurements were not obtained. However, within 24 hours prior to IABP support |
|
| Justification Form Status 2 |
Date of administration of CPR |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Systolic blood pressure |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Arterial lactate |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Aspartate transaminase |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Alanine transaminase |
|
| Justification Form Status 2 |
Test Time |
|
| Justification Form Status 2 |
Test Date |
|
| Justification Form Status 2 |
Ventricular tachycardia (VT) or ventricular fibrillation (VF) |
|
| Justification Form Status 2 |
Exception for status 2 |
|
| Justification Form Status 2 |
This exception request is specifically related to a device recall |
|
| Justification Form Status 2 |
Clinical Narrative |
|
| Justification Form Status 3 |
Primary device |
|
| Justification Form Status 3 |
Device Brand |
|
| Justification Form Status 3 |
Other specify |
|
| Justification Form Status 3 |
Date of implant/initiation |
|
| Justification Form Status 3 |
Time of implant/initiation |
|
| Justification Form Status 3 |
Ventricle support |
|
| Justification Form Status 3 |
Secondary device |
|
| Justification Form Status 3 |
Device Brand |
|
| Justification Form Status 3 |
Other specify |
|
| Justification Form Status 3 |
Date of implant/initiation |
|
| Justification Form Status 3 |
Ventricle support |
|
| Justification Form Status 3 |
Date of implant/initiation |
|
| Justification Form Status 3 |
Ventricle support |
|
| Justification Form Status 3 |
Dischargeable left ventricular assist device (LVAD) for discretionary 30 days |
|
| Justification Form Status 3 |
Multiple inotropes or a single high dose inotrope and hemodynamic monitoring |
|
| Justification Form Status 3 |
Select one of the following |
|
| Justification Form Status 3 |
Candidate is supported by either |
|
| Justification Form Status 3 |
Was the candidate on inotropic or mechanical support at the time cardiac index was obtained? |
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| Justification Form Status 3 |
Cardiac index |
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| Justification Form Status 3 |
Test Date |
|
| Justification Form Status 3 |
Test Time |
|
| Justification Form Status 3 |
Pulmonary capillary wedge pressure |
|
| Justification Form Status 3 |
Test Date |
|
| Justification Form Status 3 |
Test Time |
|
| Justification Form Status 3 |
Systolic blood pressure |
|
| Justification Form Status 3 |
Test Date |
|
| Justification Form Status 3 |
Test Time |
|
| Justification Form Status 3 |
Mechanical circulatory support device (MCSD) with hemolysis |
|
| Justification Form Status 3 |
Two separate samples collected within 48 hours of each other confirming markers of active hemolysis as evidenced by at least two of the following |
|
| Justification Form Status 3 |
Mechanical circulatory support device (MCSD) with pump thrombosis |
|
| Justification Form Status 3 |
The candidate has one of the following conditions |
|
| Justification Form Status 3 |
The candidate is supported by one of the following treatments in the hospital |
|
| Justification Form Status 3 |
Mechanical circulatory support device (MCSD) with right heart failure |
|
| Justification Form Status 3 |
Dobutamine |
|
| Justification Form Status 3 |
Date of Initiation |
|
| Justification Form Status 3 |
Dopamine |
|
| Justification Form Status 3 |
Date of Initiation |
|
| Justification Form Status 3 |
Epinephrine |
|
| Justification Form Status 3 |
Date of Initiation |
|
| Justification Form Status 3 |
Milrinone |
|
| Justification Form Status 3 |
Date of Initiation |
|
| Justification Form Status 3 |
Inhaled nitric oxide |
|
| Justification Form Status 3 |
Date of Initiation |
|
| Justification Form Status 3 |
Intravenous prostacyclin |
|
| Justification Form Status 3 |
Date of Initiation |
|
| Justification Form Status 3 |
Pulmonary capillary wedge pressure |
|
| Justification Form Status 3 |
Test Date |
|
| Justification Form Status 3 |
Test Time |
|
| Justification Form Status 3 |
Central venous pressure |
|
| Justification Form Status 3 |
Test Date |
|
| Justification Form Status 3 |
Test Time |
|
| Justification Form Status 3 |
Mechanical circulatory support device (MCSD) with device infection |
|
| Justification Form Status 3 |
Candidate is supported by an MCSD and is either experiencing a pump-related local or systemic infection with one of the following symptoms, or continues to require IV antibiotics |
|
| Justification Form Status 3 |
Mechanical circulatory support device (MCSD) with mucosal bleeding |
|
| Justification Form Status 3 |
Number of hospitalizations for mucosal bleeding within the past six months |
|
| Justification Form Status 3 |
Mechanical circulatory support device (MCSD) with aortic insufficiency (AI) |
|
| Justification Form Status 3 |
Veno-arterial extracorporeal membrane oxygenation (VA ECMO) after 7 days |
|
| Justification Form Status 3 |
Non-dischargeable, surgically implanted, non-endovascular left ventricular assist device (LVAD) after 14 days |
|
| Justification Form Status 3 |
Percutaneous endovascular circulatory support device after 14 days |
|
| Justification Form Status 3 |
Intra-aortic balloon pump after 14 days |
|
| Justification Form Status 3 |
Mechanical circulatory support device (MCSD) with life threatening ventricular arrhythmia after 7 days |
|
| Justification Form Status 3 |
Exception for status 3 |
|
| Justification Form Status 3 |
This exception request is specifically related to a device recall |
|
| Justification Form Status 3 |
Clinical Narrative |
|
| Justification Form Status 4 |
Is the candidate currently admitted to the listing transplant hospital? |
|
| Justification Form Status 4 |
Primary device |
|
| Justification Form Status 4 |
Don-Dischargeable VAD Device Brand |
|
| Justification Form Status 4 |
Other specify |
|
| Justification Form Status 4 |
Dischargeable VAD Device Brand |
|
| Justification Form Status 4 |
Other specify |
|
| Justification Form Status 4 |
Date of implant/initiation |
|
| Justification Form Status 4 |
Time of implant/initiation |
|
| Justification Form Status 4 |
Ventricle support |
|
| Justification Form Status 4 |
Secondary device |
|
| Justification Form Status 4 |
Device Brand |
|
| Justification Form Status 4 |
Other specify |
|
| Justification Form Status 4 |
Date of implant/initiation |
|
| Justification Form Status 4 |
Ventricle support |
|
| Justification Form Status 4 |
Dischargeable left ventricular assist device (LVAD) without discretionary 30 days |
|
| Justification Form Status 4 |
Inotropes without hemodynamic monitoring |
|
| Justification Form Status 4 |
Dobutamine |
|
| Justification Form Status 4 |
Date of Initiation |
|
| Justification Form Status 4 |
Milrinone |
|
| Justification Form Status 4 |
Date of Initiation |
|
| Justification Form Status 4 |
Epinephrine |
|
| Justification Form Status 4 |
Date of Initiation |
|
| Justification Form Status 4 |
Dopamine |
|
| Justification Form Status 4 |
Date of Initiation |
|
| Justification Form Status 4 |
Cardiac index |
|
| Justification Form Status 4 |
Test Date |
|
| Justification Form Status 4 |
Pulmonary capillary wedge pressure |
|
| Justification Form Status 4 |
Test Date |
|
| Justification Form Status 4 |
Congenital heart disease |
|
| Justification Form Status 4 |
Congenital Heart Disease Diagnosis |
|
| Justification Form Status 4 |
Other |
|
| Justification Form Status 4 |
Ischemic heart disease with intractable angina |
|
| Justification Form Status 4 |
Amyloidosis, or hypertrophic or restrictive cardiomyopathy |
|
| Justification Form Status 4 |
Candidate is diagnosed with at least one of the following |
|
| Justification Form Status 4 |
Candidate meets at least one of the following requirements |
|
| Justification Form Status 4 |
New York Heart Association (NYHA) Class III-IV symptoms with either |
|
| Justification Form Status 4 |
Retransplant |
|
| Justification Form Status 4 |
Exception for status 4 |
|
| Justification Form Status 4 |
Clinical Narrative |
|
| Verify ABO |
ABO |
|
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| OMB No. 0915-0157; Expiration Date: XX/XX/20XX |
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| PUBLIC BURDEN STATEMENT: |
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|
| 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 [email protected]. |