Form 109 Pediatric Liver Status 1A Initial Justification and Exte

Pediatric Liver Status 1A Initial Justification and Extension Form
Fields to be completed by members
Form Section	Field Label	Notes
Pediatric Liver Status	Status
Pediatric Liver Status	Surgeon/Physician NPI
Pediatric Liver Status	Surgeon/Physician Name
Pediatric Liver Status	Liver Status 1A Listing Date
Pediatric Liver Status	Initial Listing/Extension Form Effective Date
Pediatric Liver Status	Patient Name
Pediatric Liver Status	Patient SSN
Pediatric Liver Status	Waitlist ID
Pediatric Liver Status	Patient's Date of Birth
Pediatric Liver Status	Transplant Center
Pediatric Liver Status	Hospital Telephone Number
Pediatric Liver Status	Height (ft)
Pediatric Liver Status	Height (in)
Pediatric Liver Status	Height (cm)
Pediatric Liver Status	Date
Pediatric Liver Status	Weight (lbs)
Pediatric Liver Status	Weight (kg)
Status 1A Criteria	Fulminant liver failure
Status 1A Criteria	Primary non-function of a transplanted liver?
Status 1A Criteria	Within how many days of transplantation
Status 1A Criteria	Transplant Date
Status 1A Criteria	Draw Date
Status 1A Criteria	ALT value
Status 1A Criteria	Arterial pH value
Status 1A Criteria	Venous pH value
Status 1A Criteria	Lactate value
Status 1A Criteria	Hepatic artery thrombosis (HAT) in a transplanted liver
Status 1A Criteria	Within how many days of transplantation
Status 1A Criteria	Acute decompensated Wilson's disease
Status 1A Criteria	Clinical Narrative
Status 1A Criteria	Diagnosis
Special Case	Special case
Special Case	To qualify for Status 1A/1B, provide a current/updated clinical narrative below to support the candidate's eligibility at this status
MELD/PELD Data Collection	Serum Creatinine
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?
MELD/PELD Data Collection	Serum Sodium
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
MELD/PELD Data Collection	INR	Date
MELD/PELD Data Collection	INR - Value
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 paperwork@hrsa.gov.