3rd Party Study Generic Clearance Form (2)

SUBMISSION OF INFORMATION COLLECTION

UNDER GENERIC CLEARANCES

DATE OF REQUEST: _April 8, 2011_____________

SUB AGENCY (I/C): ____CC/OD___________

TITLE: _Survey of NIH Clinical Center Patients: Third Party Reimbursement Feasibility Project

GENERIC CLEARANCE UNDER OMB# ­__0925-0458 EXP. DATE: _12/31/2013 ___

ABSTRACT:

This survey will obtain information from clinical research participants enrolled in clinical research protocols at the NIH Clinical Center (NIH CC). The survey data will provide the NIH CC with information about research participants’ health insurance coverage and their perceptions/attitudes about the NIH CC billing their insurance carriers for standard care provided at the CC. These data will be used to inform the feasibility of collecting third party reimbursement at the NIH CC.

TOTAL ANNUAL BURDEN APPROVED: __17352_

BURDEN USED TO DATE: __70___

BURDEN THIS REQUEST: __37.8__

IS RACE AND ETHNICITY DATA COLLECTED AS REQUIRED?

______YES _X__NO______N/A

OBLIGATION TO RESPOND:

__X__ VOLUNTARY

______ REQUIRED TO OBTAIN OR RETAIN BENEFITS

______ MANDATORY

HOW WILL THIS SURVEY BE OFFERED?

_____ WEB SITE

_____ TELEPHONE INTERVIEW

_____ MAIL RESPONSE

_X_ IN PERSON INTERVIEW

_____ OTHER: ___________________________________

CONTACT INFORMATION:

NAME: __Laura M Lee_________________________________________

TELEPHONE NUMBER: _301-496-8025___________________________

EMAIL ADDRESS: [email protected]_______________________________