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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Sickle Cell Disease Treatment Demonstration Program - Quality Improvement Data Collection	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 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 %

	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

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.