| Pediatric Liver Status 1B Initial Justification and Extension Form |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| Pediatric Liver Status |
Status |
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| Pediatric Liver Status |
Surgeon/Physician NPI |
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| Pediatric Liver Status |
Surgeon/Physician Name |
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| Pediatric Liver Status |
Liver Status 1B Listing Date |
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| Pediatric Liver Status |
Initial Listing/Extension Form Effective Date |
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| Pediatric Liver Status |
Patient Name |
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| Pediatric Liver Status |
Patient SSN |
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| Pediatric Liver Status |
Waitlist ID |
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| Pediatric Liver Status |
Patient's Date of Birth |
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| Pediatric Liver Status |
Transplant Center |
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| Pediatric Liver Status |
Hospital Telephone Number |
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| Pediatric Liver Status |
Height (ft) |
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| Pediatric Liver Status |
Height (in) |
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| Pediatric Liver Status |
Height (cm) |
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| Pediatric Liver Status |
Date |
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| Pediatric Liver Status |
Weight (lbs) |
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| Pediatric Liver Status |
Weight (kg) |
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| Status 1B Criteria |
Chronic liver disease |
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| Status 1B Criteria |
Gastrointestinal bleeding requiring red blood cell replacement - Indicate amount |
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| Status 1B Criteria |
Gastrointestinal bleeding requiring red blood cell replacement - Date |
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| Status 1B Criteria |
Non-Metastatic Hepatoblastoma suitable for liver transplantation? |
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| Status 1B Criteria |
Biopsy |
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| Status 1B Criteria |
Date |
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| Status 1B Criteria |
Metabolic disease? |
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| Status 1B Criteria |
Other - Specify |
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| Status 1B Criteria |
Please specify type |
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| Status 1B Criteria |
Diagnosis |
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| MELD/PELD Data Collection |
Serum Creatinine |
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| MELD/PELD Data Collection |
Test Date |
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| MELD/PELD Data Collection |
Had dialysis twice, or 24 hours of CVVHD, within a week prior to the serum creatinine test? |
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| MELD/PELD Data Collection |
Serum Sodium |
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| MELD/PELD Data Collection |
Test Date |
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| MELD/PELD Data Collection |
Encephalopathy |
Date |
| MELD/PELD Data Collection |
Encephalopathy - Value |
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| MELD/PELD Data Collection |
Ascites |
Date |
| MELD/PELD Data Collection |
Ascites - Value |
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| MELD/PELD Data Collection |
Bilirubin |
Date |
| MELD/PELD Data Collection |
Bilirubin - Value |
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| MELD/PELD Data Collection |
Albumin |
Date |
| MELD/PELD Data Collection |
Albumin - Value |
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| MELD/PELD Data Collection |
INR |
Date |
| MELD/PELD Data Collection |
INR - Value |
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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]. |