Improving Sickle Cell Transitions of Care through Health Information Technology Phase 1

Forms and Documents

Document Name	Status
Form Form #10 Key Informant Interviews Form and Instruction	New
Form Form #9 Patients mixed ages Focus Group Form and Instruction	New
Form Form #8 Patients 18 & older Focus Group Form and Instruction	New
Form Form #7 Patients 14-17 Focus Group Form and Instruction	New
Form Form #6 Patients 9-13 Focus Group Form and Instruction	New
Form Form #5 IT Developer Focus Group Form and Instruction	New
Form Form #4 Parent/Caregiver Focus Groups Form and Instruction	New
Form Form #3 Provider Focus Groups Form and Instruction	New
Form Form #2 Demographic Questionnaire Form and Instruction	New
Form Form #1 Focus Group Screener Form and Instruction	New
SS Part B -- Improving Sickle Cell Transitions of Care through HIT Phase 1 3-7-2013.doc Supporting Statement B	2013-05-15
Attachment 13 - Justification of Focus Group Allocation by Site.docx Supplementary Document	2013-05-15
Attachment 12 - Part A Bibliographical References.docx Supplementary Document	2013-05-15
Attachment 11 - Consent & Assent Forms.doc Supplementary Document	2013-05-15
Attachment 10 - Federal Register Notice.doc Supplementary Document	2013-05-15
SS Part A -- Improving Sickle Cell Transitions of Care through HIT Phase 1 01-17-2013.doc Supporting Statement A	2013-05-14

IC Document Collections

IC ID	Document Title	Status
206959	Key Informant Interviews Form and Instruction	New
206958	Patients mixed ages Focus Group Form and Instruction	New
206957	Patients 18 & older Focus Group Form and Instruction	New
206956	Patients 14-17 Focus Group Form and Instruction	New
206955	Patients 9-13 Focus Group Form and Instruction	New
206954	IT Developer Focus Group Form and Instruction	New
206953	Parent/Caregiver Focus Groups Form and Instruction	New
206952	Provider Focus Groups Form and Instruction	New
206951	Demographic Questionnaire Form and Instruction	New
206950	Focus Group Screener Form and Instruction	New

ICR Details

OMB Control No: 0935-0213	ICR Reference No: 201305-0935-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No: 19605
Title: Improving Sickle Cell Transitions of Care through Health Information Technology Phase 1
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/12/2013
	Date Received in OIRA: 05/20/2013
Terms of Clearance: Supporting Statement 1 indicates that information collection will end May 29, 2014

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	18 Months From Approved
Responses	353	0	0
Time Burden (Hours)	249	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This project is the first phase in AHRQ's effort toward the development of a health information technology (HIT) enabled tool designed to aid adolescents and young adults with sickle cell disease (SCD) during transitions of care.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 9051	02/07/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 25085	04/29/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

IC Title	Form No.	Form Name
Focus Group Screener	Form #1	Focus Group Screening Questionnaires
Demographic Questionnaire	Form #2	Demographic Questionnaires
Provider Focus Groups	Form #3	Moderator Guide and Respondent Materials for Providers
Parent/Caregiver Focus Groups	Form #4	Moderator Guide and Respondent Materials for Parents/Caregivers
IT Developer Focus Group	Form #5	Moderator Guide for IT Developers
Patients 9-13 Focus Group	Form #6	Moderator Guide and Respondent Materials for Patients Ages 9-13
Patients 14-17 Focus Group	Form #7	Moderator Guide and Respondent Materials for Patients Ages 14-17
Patients 18 & older Focus Group	Form #8	Moderator Guide and Respondent Materials for Patients Ages 18+
Patients mixed ages Focus Group	Form #9	Moderator Guide and Respondent Materials for Patients - Mixed Ages
Key Informant Interviews	Form #10	Key Informant Interview Guides

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	353	0	0	353	0	0
Annual Time Burden (Hours)	249	0	0	249	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $176,029

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/20/2013

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