Information Collection

Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Utilization Questionnaire (pre-demonstration)

IC 197489 under ICR 201204-0915-001 · OMB 0915-0344.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Utilization Questionnaire (pre-demonstration)	Form and Instruction
3 Utilization Data Form Clean Individual Utilization Data Form_4_5_12(2).doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	3	Utilization Data Form	Clean Individual Utilization Data Form_4_5_12(2).doc		Yes	No	Printable Only

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	Previously Approved
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	675	675
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.