Information Collection

Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Health Survey

IC 197491 under ICR 201104-0915-003 · OMB 0915-0344.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0344 can be found here:

Documents and Forms

Document Name Document Type
Form 004_Sickle Cell_Ad Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Health Survey Form
004_Sickle Cell_Ad 004_Sickle Cell_Adult Health Survey Attach_Q_SF_36_Adult_HealthSurvey.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Health Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	004_Sickle Cell_Adult Health Survey	004_Sickle Cell_Adult Health Survey	Attach_Q_SF_36_Adult_HealthSurvey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 630	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,260	1,260
Annual IC Time Burden (Hours)	315	315
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.