| Adult Liver Status 1A Initial Justification and Extension Form |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| Adult Liver Status |
Status |
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| Adult Liver Status |
Surgeon/Physician NPI |
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| Adult Liver Status |
Surgeon/Physician Name |
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| Adult Liver Status |
Liver Status 1A Listing Date |
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| Adult Liver Status |
Initial Listing/Extension Form Effective Date |
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| Adult Liver Status |
Patient Name |
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| Adult Liver Status |
Patient SSN |
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| Adult Liver Status |
Waitlist ID |
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| Adult Liver Status |
Patient's Date of Birth |
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| Adult Liver Status |
Transplant Center |
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| Adult Liver Status |
Hospital Telephone Number |
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| Status 1A Criteria |
Does the candidate have a life expectancy of less than 7 days? |
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| Status 1A Criteria |
Fulminant liver failure |
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| Status 1A Criteria |
Anhepatic |
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| Status 1A Criteria |
Clinical Narrative |
|
| Status 1A Criteria |
Primary non-function of a transplanted liver? |
|
| Status 1A Criteria |
Within how many days of transplantation |
|
| Status 1A Criteria |
Transplant Date |
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| Status 1A Criteria |
Draw Date |
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| Status 1A Criteria |
AST value |
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| Status 1A Criteria |
Arterial pH value |
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| Status 1A Criteria |
Venous pH value |
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| Status 1A Criteria |
Lactate value |
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| Status 1A Criteria |
Segmental / Whole Graft |
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| Status 1A Criteria |
Hepatic artery thrombosis (HAT) in a transplanted liver? |
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| Status 1A Criteria |
Within how many days of transplantation |
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| Status 1A Criteria |
Transplant Date |
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| Status 1A Criteria |
Draw Date |
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| Status 1A Criteria |
AST value |
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| Status 1A Criteria |
Arterial pH value |
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| Status 1A Criteria |
Venous pH value |
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| Status 1A Criteria |
Lactate value |
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| Status 1A Criteria |
Acute decompensated Wilson's disease? |
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| Status 1A Criteria |
Clinical Narrative |
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| Status 1A Criteria |
Diagnosis |
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| Special Case |
Special case |
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| Special Case |
To qualify for Status 1A/1B, provide a current/updated clinical narrative below to support the candidate's eligibility at this status |
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| MELD/PELD Data Collection |
Serum Creatinine |
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| MELD/PELD Data Collection |
Test Date |
|
| 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 |
|
| MELD/PELD Data Collection |
Encephalopathy |
Date |
| MELD/PELD Data Collection |
Encephalopathy - Value |
|
| MELD/PELD Data Collection |
Ascites |
Date |
| MELD/PELD Data Collection |
Ascites - Value |
|
| MELD/PELD Data Collection |
Bilirubin |
Date |
| MELD/PELD Data Collection |
Bilirubin - Value |
|
| 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 paperwork@hrsa.gov. |