| Liver Hepatocellular Carcinoma (HCC) Initial MELD/PELD Score Exception Form |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| Diagnosis |
Transplant Center |
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| Diagnosis |
Name |
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| Diagnosis |
Date of birth |
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| Diagnosis |
Waitlist ID |
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| Diagnosis |
SSN |
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| Diagnosis |
ABO |
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| Diagnosis |
Diagnosis |
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| Diagnosis |
Candidate MELD/PELD data |
Display Only |
| Details |
Hepatocellular carcinoma (HCC) |
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| Details |
Number of Tumors |
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| Details |
Size |
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| Details |
Imaging study |
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| Details |
Imaging study date |
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| Details |
Select all that apply |
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| Details |
Biopsy confirming HCCA |
Biopsy date |
| Details |
Surgical Resection |
Surgical resection date |
| Details |
Chemical ablation |
Date |
| Details |
Chemoembolization |
Date |
| Details |
External beam radiation |
Date |
| Details |
Histotripsy |
Date |
| Details |
Radiation microspheres |
Date |
| Details |
Thermal ablation |
Date |
| Details |
Other |
Date |
| Details |
Alpha-fetoprotein (AFP) |
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| Details |
Alpha-fetoprotein (AFP) - Date |
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| Details |
Is the candidate eligible for resection? |
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| Details |
Does your assessment rule out macrovascular involvement (i.e Tumor in vein -portal or hepatic veins)?R |
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| Details |
Does your assessment rule out an extrahepatic spread? |
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| Details |
CT of chest |
Date |
| Details |
MRI of chest |
Date |
| Details |
Is the most recent tumor evaluation reported above the original/presenting tumor evaluation? |
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| Details |
Are the original tumor quantity, size, and imaging available? |
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| Details |
Date of original imaging |
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| Details |
Number of original tumors |
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| Details |
Tumor |
Size |
| Details |
Alpha-fetoprotein (AFP) |
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| Details |
Alpha-fetoprotein (AFP) - Date |
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| Details |
Reason unavailable |
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| Results |
Review results |
Display Only |
| Score |
Policy score for candidates meeting standard criteria |
Display Only |
| Score |
Please request an exception score |
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| Score |
Justification narrative |
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| Confirm |
Transplant physician name |
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| Confirm |
Transplant physician NPI |
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| Confirm |
Email decision to |
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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]. |