3rd Party Study Generic Clearance Form (2)

3rd Party Study Generic Clearance Form (2).docx

Generic Clearance for Surveys of Customers and other Partners (CC)

3rd Party Study Generic Clearance Form (2)

OMB: 0925-0458

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SUBMISSION OF INFORMATION COLLECTION

UNDER GENERIC CLEARANCES



DATE OF REQUEST: _April 8, 2011_____________


SUB AGENCY (I/C): ____CC/OD___________


TITLE: _Survey of NIH Clinical Center Patients: Third Party Reimbursement Feasibility Project


GENERIC CLEARANCE UNDER OMB# ­__0925-0458 EXP. DATE: _12/31/2013 ___


ABSTRACT:

This survey will obtain information from clinical research participants enrolled in clinical research protocols at the NIH Clinical Center (NIH CC). The survey data will provide the NIH CC with information about research participants’ health insurance coverage and their perceptions/attitudes about the NIH CC billing their insurance carriers for standard care provided at the CC. These data will be used to inform the feasibility of collecting third party reimbursement at the NIH CC.










TOTAL ANNUAL BURDEN APPROVED: __17352_


BURDEN USED TO DATE: __70___


BURDEN THIS REQUEST: __37.8__


IS RACE AND ETHNICITY DATA COLLECTED AS REQUIRED?

______YES _X__NO______N/A


OBLIGATION TO RESPOND:


__X__ VOLUNTARY


______ REQUIRED TO OBTAIN OR RETAIN BENEFITS


______ MANDATORY


HOW WILL THIS SURVEY BE OFFERED?


_____ WEB SITE


_____ TELEPHONE INTERVIEW


_____ MAIL RESPONSE


_X_ IN PERSON INTERVIEW


_____ OTHER: ___________________________________


CONTACT INFORMATION:


NAME: __Laura M Lee_________________________________________


TELEPHONE NUMBER: _301-496-8025___________________________


EMAIL ADDRESS: [email protected]_______________________________

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleGeneric Clearance Form - 04/28/2008
SubjectGeneric Clearance Form - 04/28/2008
AuthorOD/USER
File Modified0000-00-00
File Created2021-02-01

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