128 Pediatric Heart and HeartLung Status 1B Initial Justific

Pediatric Heart and HeartLung Status 1B Initial Justification Form
Fields to be completed by members
Form Section	Field Label	Notes
1B Justification Status	Form title	Display Only - Cascades from Database
1B Justification Status	Case number	Display Only - Cascades from Database
1B Justification Status	Submitted date	Display Only - Cascades from Database
1B Justification Status	Resolved date	Display Only - Cascades from Database
1B Justification Status	Status	Display Only - Cascades from Database
1B Justification Status	Effective	Display Only - Cascades from Database
1B Justification Information	Transplant Center	Display Only - Cascades from Database
1B Justification Information	Name	Display Only - Cascades from Database
1B Justification Information	Date of birth	Display Only - Cascades from Database
1B Justification Information	Waitlist ID	Display Only - Cascades from Database
1B Justification Information	SSN	Display Only - Cascades from Database
1B Justification Information	ABO	Display Only - Cascades from Database
1B Justification Diagnosis	Diagnosis	Display Only - Cascades from Database
1B Justification Criteria	By criteria
1B Justification Criteria	Is less than one year old at the time of the candidate's initial registration and has a diagnosis of hypertrophic or restrictive cardiomyopathy
1B Justification Criteria	By exception
1B Justification Justification Narrative	Justification narrative
1B Justification Authorization	Transplant physician name
1B Justification Authorization	Transplant physician NPI
1B 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 paperwork@hrsa.gov.