Sickle Cell Disease Program Evaluations

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 009_Sickle Cell_Cl 009_Sickle Cell_Client and Fam Comm Form	Form	New	Available
Form 008_Sickle Cell_QI 008_Sickle Cell_QI Instrument	Form	New	Available
Form 007_Sickle Cell_Me 007_Sickle Cell_Medical Home Index_Full	Form	New	Available
Form 007_Sickle Cell_Me 007_Sickle Cell_Medical Home Index_Short	Form	New	Available
Form 006_Sickle Cell_Pe 006_Sickle Cell_PedsQL_Child_5-7	Form	New	Available
Form 006_Sickle Cell_Pe 006_Sickle Cell_PedsQL_Child_8-12	Form	New	Available
Form 006_Sickle Cell_Pe 006_Sickle Cell_PedsQL_Child_teens	Form	New	Available
Form 005_Sickle Cell_Pe 005_Sickle Cell_PedsQL_Parents_kids5-7	Form	New	Available
Form 005_Sickle Cell_Si 005_Sickle Cell_Sickle Cell_PedsQL_toddlers	Form	New	Repair queued
Form 005_Sickle Cell_Pe 005_Sickle Cell_PedsQl_Parents_kids8-12	Form	New	Available
Form 005_Sickle Cell_Pe 005_Sickle Cell_PedsQL_Parents_Teens	Form	New	Available
Form 004_Sickle Cell_Ad 004_Sickle Cell_Adult Health Survey	Form	New	Available
Form EDITED 8-29-11 Attach_E_Individual Utilization Form_March 2010 EDITED 8-29-11	Form and Instruction	New	Available
Form EDITED 8-29-11 Attach_E_Individual Utilization Form_March 2010 EDITED 8-29-11	Form and Instruction	New	Available
Form 2 Sickle Cell Trait	Form and Instruction	New	Available
Form 1 Sickle Cell Disease	Form and Instruction	New	Available
FINALss_Part B_sickle cell disease_3-22-2011 rl1 SUBMITTED to OMB-revised_10_24_11.docx	Supporting Statement B	Uploaded 2011-12-12	Available
Attachment_A_SCDTDP_legislation.docx	Supplementary Document	Uploaded 2011-04-26	Available
FINALss_Part A_sickle cell disease_3-22-2011-rl1 SUBMITTED to OMB_revised_12-12-11.docx	Supporting Statement A	Uploaded 2011-12-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
197496	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Client Family Communication Form	Form	New	009_Sickle Cell_Client and Fam Comm Form
197495	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Quality Improvement Instrument	Form	New	008_Sickle Cell_QI Instrument
197494	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Medical Home Family Index	Form	New	007_Sickle Cell_Medical Home Index_Full
197494	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Medical Home Family Index	Form	New	007_Sickle Cell_Medical Home Index_Short
197493	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for children & adolescents	Instruction	New
197493	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for children & adolescents	Form	New	006_Sickle Cell_PedsQL_Child_5-7
197493	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for children & adolescents	Form	New	006_Sickle Cell_PedsQL_Child_8-12
197493	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for children & adolescents	Form	New	006_Sickle Cell_PedsQL_Child_teens
197492	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for Parents	Form	New	005_Sickle Cell_PedsQL_Parents_kids5-7
197492	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for Parents	Form	New	005_Sickle Cell_Sickle Cell_PedsQL_toddlers
197492	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for Parents	Form	New	005_Sickle Cell_PedsQl_Parents_kids8-12
197492	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for Parents	Form	New	005_Sickle Cell_PedsQL_Parents_Teens
197492	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for Parents	Instruction	New
197491	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Health Survey	Form	New	004_Sickle Cell_Adult Health Survey
197490	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Utilization Post	Form and Instruction	New	Attach_E_Individual Utilization Form_March 2010 EDITED 8-29-11
197489	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Utilization Questionnaire (pre-demonstration)	Form and Instruction	New	Attach_E_Individual Utilization Form_March 2010 EDITED 8-29-11
197488	Sickle Cell Disease and Newborn Screening Program (SCDNBSP) Evaluation - MDP SCT Questioniare	Instruction	New
197488	Sickle Cell Disease and Newborn Screening Program (SCDNBSP) Evaluation - MDP SCT Questioniare	Form and Instruction	New	Sickle Cell Trait
197487	Sickle Cell Disease and Newborn Screening Program (SCDNBSP) Evaluation - MDP SCD Questioniare	Form and Instruction	New	Sickle Cell Disease
197487	Sickle Cell Disease and Newborn Screening Program (SCDNBSP) Evaluation - MDP SCD Questioniare	Instruction	New

ICR Details

OMB Control No: 0915-0344	ICR Reference No: 201104-0915-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Sickle Cell Disease Program Evaluations
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: 12/30/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/27/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved
Responses	9,438	0	0
Time Burden (Hours)	3,476	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This statement is a request for Office of Management and Budget approval for evaluation and quality improvement activities of the Sickle Cell Disease and Newborn Screening Program (SCDNBSP) and the Sickle Cell Disease Treatment and Demonstration Program (SCDTDP). The purpose of the evaluations and quality improvement activities is to assess the service delivery processes and outcomes resulting from the systems of care delivered by SCDNBSP and SCDTDP networks to individuals affected by Sickle Cell Disease (SCD) who present at their sites for care.

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Authorizing Statute(s): PL: Pub.L. 108 - 357 712 Name of Law: The American Jobs Creation Act of 2004
   US Code: 42 USC 300b-1 Name of Law: Public Health Service Act
   US Code: 42 USC 701 Name of Law: Public Health Service Act
  

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:
	75 FR 52533	08/26/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 20993	04/14/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Client Family Communication Form	009_Sickle Cell_Client and Fam Comm Form	009_Sickle Cell_Client and Fam Comm Form
Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Health Survey	004_Sickle Cell_Adult Health Survey	004_Sickle Cell_Adult Health Survey
Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Medical Home Family Index	007_Sickle Cell_Medical Home Index_Short, 007_Sickle Cell_Medical Home Index_Full	007_Sickle Cell_Medical Home Index_Short ,   007_Sickle Cell_Medical Home Index_Full
Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for Parents	005_Sickle Cell_PedsQL_Parents_Teens, 005_Sickle Cell_PedsQl_Parents_kids8-12, 005_Sickle Cell_Sickle Cell_PedsQL_toddlers, 005_Sickle Cell_PedsQL_Parents_kids5-7	005_Sickle Cell_PedsQL_Parents_Teens ,   005_Sickle Cell_PedsQl_Parents_kids8-12 ,   005_Sickle Cell_Sickle Cell_PedsQL_toddlers ,   005_Sickle Cell_PedsQL_Parents_kids5-7
Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - PedsQL for children & adolescents	006_Sickle Cell_PedsQL_Child_teens, 006_Sickle Cell_PedsQL_Child_8-12, 006_Sickle Cell_PedsQL_Child_5-7	006_Sickle Cell_PedsQL_Child_teens ,   006_Sickle Cell_PedsQL_Child_8-12 ,   006_Sickle Cell_PedsQL_Child_5-7
Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Quality Improvement Instrument	008_Sickle Cell_QI Instrument	008_Sickle Cell_QI Instrument
Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Utilization Post	EDITED 8-29-11	Attach_E_Individual Utilization Form_March 2010 EDITED 8-29-11
Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Utilization Questionnaire (pre-demonstration)	EDITED 8-29-11	Attach_E_Individual Utilization Form_March 2010 EDITED 8-29-11
Sickle Cell Disease and Newborn Screening Program (SCDNBSP) Evaluation - MDP SCD Questioniare	1	Sickle Cell Disease
Sickle Cell Disease and Newborn Screening Program (SCDNBSP) Evaluation - MDP SCT Questioniare	2	Sickle Cell Trait

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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	9,438	0	0	0	9,438	0
Annual Time Burden (Hours)	3,476	0	0	0	3,476	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,671,000

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 04/27/2011

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