126 Pediatric Heart and HeartLung Status 1A Initial Justific

Pediatric Heart and HeartLung Status 1A Initial Justification Form
Fields to be completed by members
Form Section	Field Label	Notes
1A Justification Status	Form title	Display Only - Cascades from database
1A Justification Status	Case number	Display Only - Cascades from database
1A Justification Status	Submitted date	Display Only - Cascades from database
1A Justification Status	Resolved date	Display Only - Cascades from database
1A Justification Status	Status	Display Only - Cascades from database
1A Justification Status	Effective	Display Only - Cascades from database
1A Justification Information	Transplant Center	Display Only - Cascades from database
1A Justification Information	Name	Display Only - Cascades from database
1A Justification Information	Date of birth	Display Only - Cascades from database
1A Justification Information	Waitlist ID	Display Only - Cascades from database
1A Justification Information	SSN	Display Only - Cascades from database
1A Justification Information	ABO	Display Only - Cascades from database
1A Justification Diagnosis	Diagnosis	Display Only - Cascades from database
1A Justification Criteria	By criteria
1A Justification Criteria	Congenital Heart Disease Diagnosis (Check all that apply)
1A Justification Criteria	Other
1A Justification Criteria	Dobutamine
1A Justification Criteria	Dopamine
1A Justification Criteria	Milrinone
1A Justification Criteria	Epinephrine
1A Justification Criteria	Norepinephrine (Levophed)
1A Justification Criteria	IV Nitroglycerin
1A Justification Criteria	Nesiritide (Natrecor)
1A Justification Criteria	Nitroprusside (Nipride, Nitropress)
1A Justification Criteria	Phenylephrine (Neo-Synephrine)
1A Justification Criteria	Vasopressin (Pitressin)
1A Justification Criteria	Requires assistance of a mechanical circulatory support device
1A Justification Criteria	By exception
1A Justification Justification Narrative	Justification narrative
1A Justification Authorization	Transplant physician name
1A Justification Authorization	Transplant physician NPI
1A Justification Authorization	Email decision to
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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 0.27 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].