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

Document Name Document Type
Form 1 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

Information Collection (IC) Details

View Information Collection (IC)

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

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Participant Profile	Appendix C Participant Profile.pdf	Yes	Yes	Fillable Fileable Signable
Form	2	Acute Care Visit	Appendix D Acute Care Visit.pdf	Yes	Yes	Fillable Fileable Signable
Form	3	Ambulatory Care Visit	Appendix E Ambulatory Care Visit.pdf	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 %

	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

Title	Document	Date Uploaded
Appendix A PLAW-108publ357_ACA2004_Section712	Appendix A PLAW-108publ357_ACA2004_Section712.pdf	10/23/2012
Appendix B Measure Bank	Appendix B Measure Bank.pdf	10/23/2012
Appendix F and G_ SCDTDP expert panel members and TWG tables	Appendix F and G_ SCDTDP expert panel members and TWG tables.pdf	10/23/2012

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