Information Collection

Sickle Cell Disease Treatment Demonstration Program - Quality Improvement Data Collection for the Hemoglobinopathy Learning Collaborative

IC 204731 under ICR 201211-0915-001 · OMB 0915-0359.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Participant Profile Sickle Cell Disease Treatment Demonstration Program - Quality Improvement Data Collection for the Hemoglobinopathy Learning Collaborative	Form
Form 2 Acute Care Visit Sickle Cell Disease Treatment Demonstration Program - Quality Improvement Data Collection for the Hemoglobinopathy Learning Collaborative	Form
Form 3 Ambulatory Care Visit Sickle Cell Disease Treatment Demonstration Program - Quality Improvement Data Collection for the Hemoglobinopathy Learning Collaborative	Form
1 Participant Profile Appendix C Participant Profile.pdf	Form
2 Acute Care Visit Appendix D Acute Care Visit.pdf	Form
3 Ambulatory Care Visit Appendix E Ambulatory Care Visit.pdf	Form
Appendix A PLAW-108publ357_ACA2004_Section712.pdf Appendix A PLAW-108publ357_ACA2004_Section712	IC Document
Appendix B Measure Bank.pdf Appendix B Measure Bank	IC Document
Appendix F and G_ SCDTDP expert panel members and TWG tables.pdf Appendix F and G_ SCDTDP expert panel members and TWG tables	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Yes	Yes	Fillable Fileable Signable
Form	2	Yes	Yes	Fillable Fileable Signable
Form	3	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 27

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	324	324
Annual IC Time Burden (Hours)	2,700	2,700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix A PLAW-108publ357_ACA2004_Section712		10/23/2012
Appendix B Measure Bank		10/23/2012
Appendix F and G_ SCDTDP expert panel members and TWG tables		10/23/2012

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].