Information Collection

Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Medical Home Family Index

IC 197494 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 007_Sickle Cell_Me Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Medical Home Family Index	Form
007_Sickle Cell_Me 007_Sickle Cell_Medical Home Index_Short ATTACH_G_CMHI-MHI-Pediatric_Short-Version.pdf	Form
007_Sickle Cell_Me 007_Sickle Cell_Medical Home Index_Full ATTACH_F_CMHI-MHI-Pediatric_Full-Version.pdf	Form

IC Title:

Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Medical Home Family Index

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	007_Sickle Cell_Medical Home Index_Short	007_Sickle Cell_Medical Home Index_Short	ATTACH_G_CMHI-MHI-Pediatric_Short-Version.pdf		Yes	Yes	Fillable Fileable
Form	007_Sickle Cell_Medical Home Index_Full	007_Sickle Cell_Medical Home Index_Full	ATTACH_F_CMHI-MHI-Pediatric_Full-Version.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,800	1,800
Annual IC Time Burden (Hours)	450	450
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.