Form 131 Adult Heart and HeartLung Status 1 Initial Justification

Adult Heart and HeartLung Status 1 Initial Justification Form Medical Urgency Data
Fields to be completed by members
Form Section	Field Label	Notes
Status 1 Justification Form Section IV	Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO)
Status 1 Justification Form Section IV	Hemodynamic measurements
Status 1 Justification Form Section IV	Was the candidate on inotropes at the time cardiac index was obtained?
Status 1 Justification Form Section IV	Cardiac index
Status 1 Justification Form Section IV	Cardiac index - Test Date
Status 1 Justification Form Section IV	Cardiac index - Test Time
Status 1 Justification Form Section IV	Pulmonary capillary wedge pressure
Status 1 Justification Form Section IV	Pulmonary capillary wedge pressure - Test Date
Status 1 Justification Form Section IV	Pulmonary capillary wedge pressure - Test Time
Status 1 Justification Form Section IV	Systolic blood pressure
Status 1 Justification Form Section IV	Systolic blood pressure - Test Date
Status 1 Justification Form Section IV	Systolic blood pressure - Test Time
Status 1 Justification Form Section IV	Date of administration of CPR
Status 1 Justification Form Section IV	Date of administration of CPR - Test Time
Status 1 Justification Form Section IV	Systolic blood pressure
Status 1 Justification Form Section IV	Systolic blood pressure - Test Date
Status 1 Justification Form Section IV	Systolic blood pressure - Test Time
Status 1 Justification Form Section IV	Arterial lactate
Status 1 Justification Form Section IV	Arterial lactate - Test Date
Status 1 Justification Form Section IV	Arterial lactate - Test Time
Status 1 Justification Form Section IV	Aspartate transaminase
Status 1 Justification Form Section IV	Aspartate transaminase - Test Date
Status 1 Justification Form Section IV	Aspartate transaminase - Test Time
Status 1 Justification Form Section IV	Alanine transaminase
Status 1 Justification Form Section IV	Alanine transaminase - Test Date
Status 1 Justification Form Section IV	Alanine transaminase - Test Time
Status 1 Justification Form Section IV	Non-dischargeable, surgically implanted, non-endovascular biventricular support device
Status 1 Justification Form Section IV	Mechanical circulatory support device (MCSD) with life threatening ventricular arrhythmia
Status 1 Justification Form Section IV	Placement of a biventricular MCSD
Status 1 Justification Form Section IV	Patient not considered for other treatments
Status 1 Justification Form Section IV	Exception for status 1
Status 1 Justification Form Section IV	This exception request is specifically related to a device recall
Status 1 Justification Form Section IV	Clinical Narrative
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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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.