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Adult Heart and HeartLung Status 2 Criteria 5 Extension Justification Form Medical Urgency Data
ICR 202506-0915-004 · OMB 0915-0157 · Object 159416901.
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | Adult Heart and HeartLung Status 2 Criteria 5 Extension Justification Form Medical Urgency Data |
| Last Modified By | Calc |
| File Modified | 2024-11-20 |
| File Created | 2026-10-03 |
| Conversion State | complete |
Extracted Text
Adult Heart and HeartLung Status 2 Criteria 5 Extension Justification Form Medica Fields to be completed by members Form Section Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Field Label Intra-aortic balloon pump Hemodynamic measurements were obtained and within 24 hour period Cardiac index Cardiac index - Test Date Cardiac index - Test Time Pulmonary capillary wedge pressure Pulmonary capillary wedge pressure - Test Date Pulmonary capillary wedge pressure - Test Time Systolic blood pressure Systolic blood pressure - Test Date Systolic blood pressure - Test Time Select one of the following, the candidate either Was being supported by inotropic therapy according to either of the following qualifying doses A continuous infusion of at least one high dose intravenous inotrope A continuous infusion of at least two intravenous inotropes Developed ventricular tachycardia lasting at least 30 seconds or required cardioversion, defibrillation, or antitachycardia pacing after inotropic therapy was initiated in an attempt to reach the qualifying doses Hemodynamic measurements were not obtained. However, within 24 hours prior to IABP support Date of administration of CPR Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Date of administration of CPR - Test Time Systolic blood pressure _x000D_ OPTN Restricted # Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 6 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 Systolic blood pressure - Test Date Systolic blood pressure - Test Time Arterial lactate Arterial lactate - Test Date Arterial lactate - Test Time Aspartate transaminase Aspartate transaminase - Test Date Aspartate transaminase - Test Time Alanine transaminase Alanine transaminase - Test Date Alanine transaminase - Test Time Clinical Narrative Select one of the following Mean arterial pressure Mean arterial pressure - Test Date Mean arterial pressure - Test Time Cardiac index Cardiac index - Test Date Cardiac index - Test Time Pulmonary capillary wedge pressure Pulmonary capillary wedge pressure - Test Date Pulmonary capillary wedge pressure - Test Time SvO2 SvO2 - Test Date SvO2 - Test Time _x000D_ OPTN Restricted # Status 2 Extension Criteria 5 Within 48 hours prior to the status expiring, the candidate was being supported by inotropic therapy according to either of the following qualifying doses: A continuous infusion of at least one high dose intravenous inotrope A continuous infusion of at least two intravenous inotropes Status 2 Extension Criteria 5 Status 2 Extension Criteria 5 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 t functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monit organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respo unless it displays a currently valid OMB control number. The OMB control number for this information collection is XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data c Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed b Security of Federal Automated Information Systems, and the Departments Automated Information Systems Securit reporting burden for this collection of information is estimated to average 0.27 hours per response, including the ti searching existing data sources, and completing and reviewing the collection of information. Send comments regar other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information C Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. _x000D_ OPTN Restricted # tification Form Medical Urgency Data mbers Notes Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only _x000D_ OPTN Restricted # Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only Display only _x000D_ OPTN Restricted # this information in order to perform the following OPTN n the OPTN; and to monitor compliance of member n is not required to respond to, a collection of information information collection is 0915-0157 and it is valid until R §121.11(b)(2). All data collected will be subject to Privacy non-profit OPTN also are well protected by a number of the uirements as prescribed by OMB Circular A-130, Appendix III, ormation Systems Security Program Handbook. The public response, including the time for reviewing instructions, on. Send comments regarding this burden estimate or any en, to HRSA Information Collection Clearance Officer, 5600 _x000D_ OPTN Restricted #