OMB control number
Chart Abstraction of Ryan White HIV/AIDS Program Recipient Data
OMB 0906-0050 · HHS/HRSA.
OMB 0906-0050
Health Resources and Services Administration is required to assess the quality of care provided by Ryan White HIV/AIDS Program recipients. HHS guidelines and U.S. Preventative Services Task Force guidelines serve as the basis for assessing the quality of care within the RWHAP. HRSA will collect patient level clinical information from a representative sample of 50 RWHAP recipients or subrecipients annually for three years. The information collected will be used to assess the quality of care provided through the RWHAP.
The latest form for Chart Abstraction of Ryan White HIV/AIDS Program Recipient Data expires 2023-04-30 and is listed under ICR 201912-0906-001.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form 3 Pre-Site Visit Interview | Form |
| Form 2 Site Screening Interview | Form |
 Form 1 Medical Record Data Abstraction | Form |
| Proposed Timeline for Chart Abstraction Client Level Data Collection.docx | Supplementary Document |
| Data dictionary.pdf | Supplementary Document |
| IRB Approval.pdf | Supplementary Document |
| Legislation.pdf | Supplementary Document |
| Privacy Impact Assessment.pdf | Supplementary Document |
| Supporting Statement B Feb 2020.docx | Supporting Statement B |
| Supporting Statement A March 2020.docx | Supporting Statement A |
 Pre-Site Visit Interview |
Form |
| Site Screening Interview |
Form |
| Medical Record Data Abstraction |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 201912-0906-001 | New collection (Request for a new OMB Control Number) | 2019-12-03 | Approved with change |
OMB Details
Medical Record Data Abstraction
Federal Enterprise Architecture: Health - Health Care Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form 1 | Medical Record Data Abstraction Screenshots.pdf | Fillable Fileable | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.