Form 008_Sickle Cell_QI 008_Sickle Cell_QI 008_Sickle Cell_QI Instrument

OMB Number: xxxx-xxxx

Expiration Date:

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0915-xxxx.  Public reporting burden for this collection of information is estimated to average 30 minutes per respondent annually, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland, 20857.

SCDTDP Quality Improvement Instrument

This survey asks for information regarding your participation in the SCDTDP Hemoglobinopathy Learning Collaborative. The survey will be completed on a monthly basis throughout the duration of the Collaborative.

• Quality Improvement Questions:

• For your specific network sites, please provide the following patient-related information:

• Percent of SC individuals with treatment plan reviewed in past 12 months ______

• Percent of newborns screened for SC trait ______

• Percent of positive screens with timely follow-up ______

• Percent of SC individuals with up to date immunizations ______

• Percent of SC individuals with documented PCP visited in past 12 months ______

• Improvement Project Questions:

• For your specific Learning Collaborative Team, please provide the following site team-related information:

• Percent of teams that meet at least bi-weekly ______

• Percent of teams participating in calls ______

• Percent of teams rated 4 or above on project assessment ______

(1 to 5, where 1 is poor, 2 is fair, 3 is good, 4 is very good, 5 is excellent)