Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Utilization Questionnaire (pre-demonstration)

Sickle Cell Disease Program Evaluations

Documents and Forms

Document Name Document Type
Form 3 Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Utilization Questionnaire (pre-demonstration) Form and Instruction
3 Utilization Data Form Clean Individual Utilization Data Form_4_5_12(2).doc Form and Instruction

Information Collection (IC) Details

IC Title:	Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Utilization Questionnaire (pre-demonstration)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Utilization Data Form	Clean Individual Utilization Data Form_4_5_12(2).doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	675	675
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.