Information Collection

ADAP site visit

IC 202186 under ICR 201205-0915-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 ADAP site visit	Form
Appendix C ADAP Participant Information Sheet final 3-30-12.docx	Instruction
1 Local ADAP Director/Lead Discussion Guide - ADAP Director.docx	Form
5 Medicaid Lead Discussion Guide - Medicaid Policy Lead.docx	Form
2 Local ADAP Staff Discussion Guide - Local ADAP enrollment - Dispensing Site.docx	Form
3 Part B Lead Discussion Guide - Part B Grant Lead and Office HIV-AIDS Staff.docx	Form
4 Pharmacy Benefit Management Representative Discussion Guide - ADAP Pharmacy Benefit Mangement Administrator.docx	Form
6 State PAP Administrator Discussion Guide - State Pharmaceutical Assistance Program Administrator.docx	Form
7 Insurance Exchange and State Plan Administrators Discussion Guide - Insurace Exchange and State Plan Administrators.docx	Form
Appendix B ADAP Evaluation Plan FINAL.doc Full Evaluation Plan	IC Document
Appendix A Ryan White legislation.pdf Ryan White Legislation	IC Document

IC Title:

ADAP site visit

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Local ADAP Director/Lead	Discussion Guide - ADAP Director.docx	Yes	Yes	Paper Only
Form	5	Medicaid Lead	Discussion Guide - Medicaid Policy Lead.docx	Yes	Yes	Paper Only
Form	2	Local ADAP Staff	Discussion Guide - Local ADAP enrollment - Dispensing Site.docx	Yes	Yes	Paper Only
Form	3	Part B Lead	Discussion Guide - Part B Grant Lead and Office HIV-AIDS Staff.docx	Yes	Yes	Paper Only
Form	4	Pharmacy Benefit Management Representative	Discussion Guide - ADAP Pharmacy Benefit Mangement Administrator.docx	Yes	Yes	Paper Only
Form	6	State PAP Administrator	Discussion Guide - State Pharmaceutical Assistance Program Administrator.docx	Yes	Yes	Paper Only
Form	7	Insurance Exchange and State Plan Administrators	Discussion Guide - Insurace Exchange and State Plan Administrators.docx	Yes	Yes	Paper Only
Instruction			Appendix C ADAP Participant Information Sheet final 3-30-12.docx	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 72

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	72	72
Annual IC Time Burden (Hours)	104	104
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Full Evaluation Plan	Appendix B ADAP Evaluation Plan FINAL.doc	05/02/2012
Ryan White Legislation	Appendix A Ryan White legislation.pdf	05/02/2012

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