130 Adult Heart and HeartLung Status 1-6 Justification Form

Adult Heart and HeartLung Status 1-6 Justification Form Risk Stratification Data
Fields to be completed by members
Form Section	Field Label	Notes
Heart Justification Forms 1-6 Risk Stratification Data	Total number of prior sternotomies
Heart Justification Forms 1-6 Risk Stratification Data	Any prior history of stroke?
Heart Justification Forms 1-6 Risk Stratification Data	Any prior history of peripheral thromboembolic events?
Heart Justification Forms 1-6 Risk Stratification Data	Number of hospitalizations for heart failure in last 12 months
Heart Justification Forms 1-6 Risk Stratification Data	Is the candidate on a diuretic?
Heart Justification Forms 1-6 Risk Stratification Data	Furosemide - Amount
Heart Justification Forms 1-6 Risk Stratification Data	Furosemide - IV/PO
Heart Justification Forms 1-6 Risk Stratification Data	Torsemide - Amount
Heart Justification Forms 1-6 Risk Stratification Data	Torsemide - IV/PO
Heart Justification Forms 1-6 Risk Stratification Data	Bumetanide - Amount
Heart Justification Forms 1-6 Risk Stratification Data	Bumetanide - IV/PO
Heart Justification Forms 1-6 Risk Stratification Data	Chlorothiazide - Amount
Heart Justification Forms 1-6 Risk Stratification Data	Chlorothiazide - IV/PO
Heart Justification Forms 1-6 Risk Stratification Data	Metolazone - Amount
Heart Justification Forms 1-6 Risk Stratification Data	Metolazone - IV/PO
Heart Justification Forms 1-6 Risk Stratification Data	Other diuretic - Name
Heart Justification Forms 1-6 Risk Stratification Data	Other diuretic - Amount
Heart Justification Forms 1-6 Risk Stratification Data	Other diuretic - IV/PO
Heart Justification Forms 1-6 Risk Stratification Data	Is the candidate on vasoactive support?
Heart Justification Forms 1-6 Risk Stratification Data	Dobutamine
Heart Justification Forms 1-6 Risk Stratification Data	Dopamine
Heart Justification Forms 1-6 Risk Stratification Data	Milrinone
Heart Justification Forms 1-6 Risk Stratification Data	Epinephrine
Heart Justification Forms 1-6 Risk Stratification Data	Norepinephrine
Heart Justification Forms 1-6 Risk Stratification Data	Vasopressin
Heart Justification Forms 1-6 Risk Stratification Data	Is the candidate on anti-arrhythmics?
Heart Justification Forms 1-6 Risk Stratification Data	Is the candidate on pulmonary vasodilators?
Heart Justification Forms 1-6 Risk Stratification Data	Pulmonary Vasodilators Specify
Heart Justification Forms 1-6 Risk Stratification Data	Is the candidate on dialysis?
Heart Justification Forms 1-6 Risk Stratification Data	Is the candidate on continuous invasive mechanical ventilation?
Heart Justification Forms 1-6 Risk Stratification Data	Most Recent Cardiopulmonary Stress Test
Heart Justification Forms 1-6 Risk Stratification Data	Peak O2 consumption
Heart Justification Forms 1-6 Risk Stratification Data	Respiratory exchange ratio (RER)
Heart Justification Forms 1-6 Risk Stratification Data	VE/VCO2
Heart Justification Forms 1-6 Risk Stratification Data	Most Recent Sensitization Data
Heart Justification Forms 1-6 Risk Stratification Data	CPRA
Heart Justification Forms 1-6 Risk Stratification Data	PRA typing method
Heart Justification Forms 1-6 Risk Stratification Data	PRA typing method - Other Specify
Heart Justification Forms 1-6 Risk Stratification Data	MFI threshold
Heart Justification Forms 1-6 Risk Stratification Data	Most Recent Hemodynamic Data
Heart Justification Forms 1-6 Risk Stratification Data	Hemodynamic data obtained using
Heart Justification Forms 1-6 Risk Stratification Data	Hemodynamic data obtained using - Other Specify
Heart Justification Forms 1-6 Risk Stratification Data	Hemodynamic values were obtained when candidate was on
Heart Justification Forms 1-6 Risk Stratification Data	Systolic blood pressure
Heart Justification Forms 1-6 Risk Stratification Data	Diastolic blood pressure
Heart Justification Forms 1-6 Risk Stratification Data	Resting heart rate (on same date as hemodynamic tests)
Heart Justification Forms 1-6 Risk Stratification Data	Central venous pressure
Heart Justification Forms 1-6 Risk Stratification Data	Pulmonary artery systolic pressure
Heart Justification Forms 1-6 Risk Stratification Data	Pulmonary artery diastolic pressure
Heart Justification Forms 1-6 Risk Stratification Data	Mean pulmonary artery pressure
Heart Justification Forms 1-6 Risk Stratification Data	Value obtained for PCWP or LVEDP
Heart Justification Forms 1-6 Risk Stratification Data	PCWP/LVEDP - Amount
Heart Justification Forms 1-6 Risk Stratification Data	Cardiac output
Heart Justification Forms 1-6 Risk Stratification Data	Cardiac index
Heart Justification Forms 1-6 Risk Stratification Data	Mixed venous oxygen saturation (SvO2)
Heart Justification Forms 1-6 Risk Stratification Data	Hemoglobin at time of SvO2
Heart Justification Forms 1-6 Risk Stratification Data	Most Recent Data for VAD patients
Heart Justification Forms 1-6 Risk Stratification Data	LDH
Heart Justification Forms 1-6 Risk Stratification Data	LDH - Test date
Heart Justification Forms 1-6 Risk Stratification Data	Plasma free hemoglobin
Heart Justification Forms 1-6 Risk Stratification Data	Plasma free hemoglobin - Test date
Heart Justification Forms 1-6 Risk Stratification Data	Has the candidate experienced hemoglobinuria?
Heart Justification Forms 1-6 Risk Stratification Data	Most Recent Heart Failure Severity Data
Heart Justification Forms 1-6 Risk Stratification Data	Serum sodium
Heart Justification Forms 1-6 Risk Stratification Data	Serum sodium - Test date
Heart Justification Forms 1-6 Risk Stratification Data	Serum creatinine
Heart Justification Forms 1-6 Risk Stratification Data	Serum creatinine - Test date
Heart Justification Forms 1-6 Risk Stratification Data	BUN
Heart Justification Forms 1-6 Risk Stratification Data	BUN - Test date
Heart Justification Forms 1-6 Risk Stratification Data	Serum albumin
Heart Justification Forms 1-6 Risk Stratification Data	Serum albumin - Test date
Heart Justification Forms 1-6 Risk Stratification Data	AST
Heart Justification Forms 1-6 Risk Stratification Data	AST - Test date
Heart Justification Forms 1-6 Risk Stratification Data	Serum bilirubin
Heart Justification Forms 1-6 Risk Stratification Data	Serum bilirubin - Test date
Heart Justification Forms 1-6 Risk Stratification Data	Arterial lactate
Heart Justification Forms 1-6 Risk Stratification Data	Arterial lactate - Test date
Heart Justification Forms 1-6 Risk Stratification Data	INR
Heart Justification Forms 1-6 Risk Stratification Data	INR - Test date
Heart Justification Forms 1-6 Risk Stratification Data	Brain natriuretic peptide test performed?
Heart Justification Forms 1-6 Risk Stratification Data	BNP test type
Heart Justification Forms 1-6 Risk Stratification Data	BNP/NT Pro BNP - Amount
Heart Justification Forms 1-6 Risk Stratification Data	BNP/NT Pro BNP - Amount - Test date
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].