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Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Health Survey
Sickle Cell Disease Program Evaluations
OMB: 0915-0344
IC ID: 197491
OMB.report
HHS/HSA
OMB 0915-0344
ICR 201204-0915-001
IC 197491
( )
Documents and Forms
Document Name
Document Type
Form 5
Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Health Survey
Form
5 Short Form 8 Health Survey (adult)
Indicator Crosswalk for SF36-SF8 and PedsQL-PedsQL SF 15.xls
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Health Survey
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
5
Short Form 8 Health Survey (adult)
Indicator Crosswalk for SF36-SF8 and PedsQL-PedsQL SF 15.xls
Yes
Yes
Fillable Fileable
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:
630
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
1,260
0
0
0
0
1,260
Annual IC Time Burden (Hours)
126
0
0
-189
0
315
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
