Information Collection

Treatment of Pediatric ADHD: An Assessment of State Medicaid Policies

IC 224398 under ICR 201412-0920-011 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Treatment of Pediatric ADHD: An Assessment of State Medicaid Policies	Form
Prior Authorization Policies for Pediatric ADHD Medicati Attachment B- Instrument_PDF Version.pdf	Form
Attachment A- Instrument_Word Version.docx Word Version of the Information Collection Instrument (for reference)	IC Document
Attachment C- Notification Email.docx Notification Email	IC Document
Attachment D- Launch Email.docx Launch Email	IC Document
Attachment E- Reminder Email.docx Reminder Email	IC Document
ADHD-PA-SSA.docx Supporting Statement Part A	IC Document
ADHD-PA-SSB.docx Supporting Statement Part B	IC Document

IC Title:

Treatment of Pediatric ADHD: An Assessment of State Medicaid Policies

Agency IC Tracking Number:

0920-17BD

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Prior Authorization Policies for Pediatric ADHD Medication Prescriptions	Attachment B- Instrument_PDF Version.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	51	51
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Word Version of the Information Collection Instrument (for reference)	Attachment A- Instrument_Word Version.docx	11/10/2016
Notification Email	Attachment C- Notification Email.docx	11/10/2016
Launch Email	Attachment D- Launch Email.docx	11/10/2016
Reminder Email	Attachment E- Reminder Email.docx	11/10/2016
Supporting Statement Part A	ADHD-PA-SSA.docx	11/10/2016
Supporting Statement Part B	ADHD-PA-SSB.docx	11/10/2016

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