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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.