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Sickle Cell Disease Treatment Demonstration Program - Quality Improvement Data Collection for the Hemoglobinopathy Learning Collaborative
Sickle Cell Disease Treatment Demonstration Program QI Measures
OMB: 0915-0359
IC ID: 204731
OMB.report
HHS/HSA
OMB 0915-0359
ICR 201211-0915-001
IC 204731
( )
Documents and Forms
Document Name
Document Type
Form 1
Sickle Cell Disease Treatment Demonstration Program - Quality Improvement Data Collection for the Hemoglobinopathy Learning Collaborative
Form
1 Participant Profile
Appendix C Participant Profile.pdf
Form
2 Acute Care Visit
Appendix D Acute Care Visit.pdf
Form
3 Ambulatory Care Visit
Appendix E Ambulatory Care Visit.pdf
Form
Appendix A PLAW-108publ357_ACA2004_Section712.pdf
Appendix A PLAW-108publ357_ACA2004_Section712
IC Document
Appendix B Measure Bank.pdf
Appendix B Measure Bank
IC Document
Appendix F and G_ SCDTDP expert panel members and TWG tables.pdf
Appendix F and G_ SCDTDP expert panel members and TWG tables
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Sickle Cell Disease Treatment Demonstration Program - Quality Improvement Data Collection for the Hemoglobinopathy Learning Collaborative
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
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
1
Participant Profile
Appendix C Participant Profile.pdf
Yes
Yes
Fillable Fileable Signable
Form
2
Acute Care Visit
Appendix D Acute Care Visit.pdf
Yes
Yes
Fillable Fileable Signable
Form
3
Ambulatory Care Visit
Appendix E Ambulatory Care Visit.pdf
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
27
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
324
0
324
0
0
0
Annual IC Time Burden (Hours)
2,700
0
2,700
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Appendix A PLAW-108publ357_ACA2004_Section712
Appendix A PLAW-108publ357_ACA2004_Section712.pdf
10/23/2012
Appendix B Measure Bank
Appendix B Measure Bank.pdf
10/23/2012
Appendix F and G_ SCDTDP expert panel members and TWG tables
Appendix F and G_ SCDTDP expert panel members and TWG tables.pdf
10/23/2012
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.