Sickle Cell Disease Treatment Demonstration Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form medical home index Sickle Cell Treatment Demonstration Medical Home Family Index	Form	New	Available
Form PedsQL Sickle Cell Treatment Demonstration PedsQL for children	Form	New	Available
Form PedsQL Sickle Cell Treatment Demonstration PedsQL for parents	Form	New	Available
Form SF 36 Sickle Cell Treatment Demonstration health survey	Form	New	Available
Form 1 Sickle Cell Treatment utilization form-post	Form	New	Available
Form 1 Sickle Cell Treatment utilization form	Form	New	Available
scdtdp assent_revised.doc	Supplementary Document	Uploaded 2008-10-07	Available
scell response to OMB.doc	Supplementary Document	Uploaded 2008-10-07	Available
ss scell b.doc	Supporting Statement B	Uploaded 2008-07-28	Available
scdtdp parent consent_rev.doc	Supplementary Document	Uploaded 2008-10-07	Available
scdtdp adult consent_rev.doc	Supplementary Document	Uploaded 2008-10-07	Available
scell child assent.doc	Supplementary Document	Uploaded 2008-07-28	Available
scell references.doc	Supplementary Document	Uploaded 2008-07-28	Available
scdtdp overview.doc	Supplementary Document	Uploaded 2008-07-28	Available
ss scell a.doc	Supporting Statement A	Uploaded 2008-07-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
185932	Sickle Cell Treatment Demonstration Medical Home Family Index	Form	New
185931	Sickle Cell Treatment Demonstration PedsQL for children	Form	New
185930	Sickle Cell Treatment Demonstration PedsQL for parents	Form	New
185929	Sickle Cell Treatment Demonstration health survey	Form	New
185928	Sickle Cell Treatment utilization form-post	Form	New
185927	Sickle Cell Treatment utilization form	Form	New

ICR Details

OMB Control No: 0915-0320	ICR Reference No: 200807-0915-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Sickle Cell Disease Treatment Demonstration Program
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/07/2008
	Date Received in OIRA: 07/30/2008
Terms of Clearance: This ICR is approved as per HRSA memo of 10/6/08.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2010	22 Months From Approved
Responses	2,600	0	0
Time Burden (Hours)	950	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This project is a new activity, designed for the purpose of evaluating the effectiveness of HRSA's Sickle Cell Disease Treatment Demonstration Program. This demonstration was designed for the purpose of providing coordinated, comprehensive care to families with Sickle Cell disease. In FY 2006, HRSA awarded 4 grants to establish geographically distributed regional networks to work with Sickle Cell Disease centers and community based support organizations to provide care. This evaluation will provide information to help determine the effectiveness of the demonstration projects in achieving its goals.

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Authorizing Statute(s): PL: Pub.L. 108 - 357 712 Name of Law: American Jobs Creation Act of 2004
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 870	01/04/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 43943	07/29/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Sickle Cell Treatment Demonstration Medical Home Family Index	medical home index	medical home index
Sickle Cell Treatment utilization form	1	individual form
Sickle Cell Treatment utilization form-post	1	individual form
Sickle Cell Treatment Demonstration health survey	SF 36	SF 36
Sickle Cell Treatment Demonstration PedsQL for parents	PedsQL	PedsQL
Sickle Cell Treatment Demonstration PedsQL for children	PedsQL	PedsQL

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,600	0	0	2,600	0	0
Annual Time Burden (Hours)	950	0	0	950	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This ICR is a new activity. It is a program change showing an increase in agency burden for the purpose of conducting an evaluation of a new demonstration program for the prevention and treatment of Sickle Cell Disease.

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Annual Cost to Federal Government: $620,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/30/2008

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