Information Collection

Sickle Cell Disease Treatment Demonstration Program - Quality Improvement Data Collection

IC 222219 under ICR 201606-0906-003 · OMB 0906-0019.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form D Sickle Cell Disease Treatment Demonstration Program - Quality Improvement Data Collection	Form and Instruction
D Appendix D_ SCDTDP Data Collection Form Appendix D_ SCDTDP Data Collection Form.pdf	Form and Instruction
E Appendix E_SCDTDP Measure Specifications Appendix E_SCDTDP Measure Specifications.xlsx	Form and Instruction
F Appendix F_SCDTDP_Data Request Form Appendix F_SCDTDP_Data Request Form.xlsx	Form and Instruction
G Appendix G Tracking Project Performance Measures Templat Appendix G Tracking Project Performance Measures Template.docx	Form and Instruction
H Appendix H_Project Performance-Outcome Measure Detail Sh Appendix H_Project Performance-Outcome Measure Detail Sheet Template.docx	Form and Instruction

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.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	D	Appendix D_ SCDTDP Data Collection Form	Appendix D_ SCDTDP Data Collection Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	E	Appendix E_SCDTDP Measure Specifications	Appendix E_SCDTDP Measure Specifications.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	F	Appendix F_SCDTDP_Data Request Form	Appendix F_SCDTDP_Data Request Form.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	G	Appendix G Tracking Project Performance Measures Template	Appendix G Tracking Project Performance Measures Template.docx	Yes	Yes	Fillable Fileable
Form and Instruction	H	Appendix H_Project Performance-Outcome Measure Detail Sheet Template	Appendix H_Project Performance-Outcome Measure Detail Sheet Template.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4

Number of Respondents for Small Entity: 4

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	320	320
Annual IC Time Burden (Hours)	1,920	1,920
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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