Pediatric Lung Priority 1 Status Justification Form

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

Pediatric Lung Priority 1 Status Form

Pediatric Lung Priority form must be completed and received by UNOS through UNet^SM in order to list a candidate as Priority 1, or extend the candidate's listing as Priority 1 in accordance with the criteria specified in policy. Submission of all data through UNet^SM is required for addition to the waiting list or any modification in Priority, including removal from the waiting list. If this form is not submitted to update the candidate's record to extend the Priority within the time frames described in policy, the candidate shall be automatically downgraded to Priority 2.

Demographic Information

Age group: Verify the candidate age group.

Surgeon/physician NPI: Enter the surgeon/physician's NPI number. The NPI must be 10 digits. This is a required field.

Surgeon/physician name: Enter the surgeon/physician's name. This is a required field.

Section I

Patient Name: Verify the patient's name is correct.

Patient SSN: Verify the patient’s social security number is correct.

Waitlist ID: Verify the candidate's Waitlist ID number is correct.

Transplant Center: Verify the transplant center code is correct.

Hospital Telephone Number: Enter the hospital telephone number.

Section II

Patient Diagnosis: Verify the patient’s diagnosis.

Age: Verify the patient’s age.

Height: Verify the patient’s height.

Weight: Verify the patient’s weight.

For a candidate to qualify as Priority 1, the candidate must meet one of the three criteria listed under the Respiratory Failure category or one of the three criteria listed under the Pulmonary Hypertension category.

Respiratory failure defined as: Check all that apply and enter the date the criterion was met.

• Requiring continuous mechanical ventilation

• Requiring supplemental oxygen delivered by any means to achieve FiO2 greater than 50% in order to maintain oxygen saturation levels greater than 90%

• Having an arterial or capillary PCO2 greater than 50mmHg, or a venous PCO2 greater than 56 mmHg

Please provide any additional information as necessary: Enter additional information (maximum of 5000 characters).

Pulmonary hypertension defined as: Check all that apply and enter the date the criterion was met.

• Having pulmonary vein stenosis involving 3 or more vessels

• 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

• Exhibiting suprasystemic PA pressure on cardiac catheterization

Please provide any additional information as necessary: Enter additional information (maximum of 5000 characters).

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.   

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