Form 129 Adult Heart and HeartLung Status 1-6 Justification Form

Adult Heart and HeartLung Status 1-6 Justification Form Demographic Data
Fields to be completed by members
Form Section	Field Label	Notes
Heart Justification Forms 1-6 Demographic Data	Age group	Display Only
Heart Justification Forms 1-6 Demographic Data	Status	Display Only
Heart Justification Forms 1-6 Demographic Data	Surgeon/Physician NPI
Heart Justification Forms 1-6 Demographic Data	Surgeon/Physician name
Heart Justification Forms 1-6 Section I	Heart status 1-6 initial listing date	Display Only
Heart Justification Forms 1-6 Section I	Form effective date	Display Only
Heart Justification Forms 1-6 Section I	Name	Display Only
Heart Justification Forms 1-6 Section I	SSN	Display Only
Heart Justification Forms 1-6 Section I	Waitlist ID	Display Only
Heart Justification Forms 1-6 Section I	Date of birth	Display Only
Heart Justification Forms 1-6 Section I	Transplant center	Display Only
Heart Justification Forms 1-6 Section I	Hospital telephone number
Heart Justification Forms 1-6 Section II	Diagnosis	Display Only
Heart Justification Forms 1-6 Section II	Age	Display Only
Heart Justification Forms 1-6 Section II	Height	Display Only
Heart Justification Forms 1-6 Section II	Weight	Display Only
Heart Justification Forms 1-6 Section II	Is the candidate currently admitted to the listing transplant hospital?
Heart Justification Forms 1-6 Section III	Primary device
Heart Justification Forms 1-6 Section III	Device brand
Heart Justification Forms 1-6 Section III	Other specify
Heart Justification Forms 1-6 Section III	Date of implant/initiation
Heart Justification Forms 1-6 Section III	Time of implant/initiation
Heart Justification Forms 1-6 Section III	Ventricle support
Heart Justification Forms 1-6 Section III	Secondary device
Heart Justification Forms 1-6 Section III	Device brand
Heart Justification Forms 1-6 Section III	Other specify
Heart Justification Forms 1-6 Section III	Date of implant/initiation
Heart Justification Forms 1-6 Section III	Ventricle support
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.