Form 147 Pediatric Lung Priority 1 Status Justification Form

Pediatric Lung Priority 1 Status Justification Form
Fields to be completed by members
Form Section	Field Label	Notes
Pediatric Lung Priority Demographic Information	Age Group	Display Only - Cascades from database
Pediatric Lung Priority Demographic Information	Surgeon/Physician NPI
Pediatric Lung Priority Demographic Information	Surgeon/Physician Name
Pediatric Lung Priority Section I	Patient Name	Display Only - Cascades from database
Pediatric Lung Priority Section I	Patient SSN	Display Only - Cascades from database
Pediatric Lung Priority Section I	Waitlist ID	Display Only - Cascades from database
Pediatric Lung Priority Section I	Transplant Center	Display Only - Cascades from database
Pediatric Lung Priority Section I	Hospital Telephone Number
Pediatric Lung Priority Section I	Requested By
Pediatric Lung Priority Section II	Patient Diagnosis	Display Only - Cascades from database
Pediatric Lung Priority Section II	Age	Display Only - Cascades from database
Pediatric Lung Priority Section II	Height	Display Only - Cascades from database
Pediatric Lung Priority Section II	Weight	Display Only - Cascades from database
Pediatric Lung Priority Section II	Respiratory failure defined as: Requiring continuous mechanical ventilation - Date Criterion Met
Pediatric Lung Priority Section II	Respiratory failure defined as: Requiring supplemental oxygen delivered by any means to achieve FiO2 greater than 50% in order to maintain oxygen saturation levels greater than 90% - Date Criterion Met
Pediatric Lung Priority Section II	Respiratory failure defined as: Having an arterial or capillary PCO2 greater than 50mmHg, or a venous PCO2 greater than 56 mmHg - Date Criterion Met
Pediatric Lung Priority Section II	Respiratory failure - Please provide any additional information as necessary
Pediatric Lung Priority Section II	Pulmonary hypertension defined as: Having pulmonary vein stenosis involving 3 or more vessels - Date Criterion Met
Pediatric Lung Priority Section II	Pulmonary hypertension defined as: Exhibiting any of the following, in spite of medical therapy: suprasystemic PA pressure by echocardiogram estimate, cardiac index less than 2 L/min/m2, syncope or hemoptysis - Date Criterion Met
Pediatric Lung Priority Section II	Pulmonary hypertension defined as: Exhibiting suprasystemic PA pressure on cardiac catheterization - Date Criterion Met
Pediatric Lung Priority Section II	Pulmonary hypertension defined as: Pulmonary hypertension - Please provide any additional information as necessary
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.