OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Using Real-time Prescription and Insurance Claims Data to Support the HIV Care Continuum

ICR 202109-0920-005 · OMB 0920-1361 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Post-Consultation Questionnaire Form and Instruction New Repair queued
Peer-to-Peer Clinician Consultation [Provider Participants] Form and Instruction New Repair queued
Peer-to-Peer Clinician Consultation [HIV Expert Consultants] Form and Instruction New Repair queued
Phase II Interview for Participants of Patient-level Intervention Form and Instruction New Repair queued
Phase I Interview for Participants of Patient-level Intervention Form and Instruction New Repair queued
PositiveLinks Verbal Consent and Enrollment Form and Instruction New Missing upstream
HIPAA Authorization [Control Patient Participants] Form New Repair queued
HIPAA Authorization [Patients of Providers in Provider-level Intervention] Form New Available
HIPAA Authorization [Participants of Patient-level Intervention] Form New Available
Verbal Consent [Control Patient Participants] Form and Instruction New Repair queued
Verbal Consent [Patients of Providers in Provider-level Intervention] Form and Instruction New Repair queued
Verbal Consent [Providers] Form and Instruction New Repair queued
Verbal Consent [Participants of Patient-level Intervention] Form and Instruction New Repair queued
SSA_AIMS_101821.docx Supporting Statement A Uploaded 2021-10-18 Repair queued
Att 19_60-Day FRN.pdf Supplementary Document Uploaded 2021-10-18 Repair queued
Att 18_Institutional Review Board approval letter.pdf Supplementary Document Uploaded 2021-10-18 Repair queued
Att 17b_Certified letter_control participants.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 17a_Certified letter_participants.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 16_Privacy Impact Assessment.pdf Supplementary Document Uploaded 2021-10-18 Repair queued
Att 15_PositiveLinks data elements.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 12b_PositiveLinks Program and Service Agreement letter.docx Supplementary Document Uploaded 2021-10-18 Missing upstream
Att 7c_Contact protocol_control participants.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 7b_Contact protocol_provider participants.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 7a_Contact protocol_participants.docx Supplementary Document Uploaded 2021-10-18 Missing upstream
Att 6b_Study information sheet_provider participants.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 6a_Study information sheet _providers of participants.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 5d_Courtesy notification letter to providers of participants.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 5c_Introductory letter_control participants.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 5b_Introductory letter_provider participants.docx Supplementary Document Uploaded 2021-10-18 Missing upstream
Att 5a_Introductory letter_participants.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 4_Virginia Care Marker Data abstraction.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 3_Virginia Medicaid data abstraction.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 2_Technical Appendix_09292021.docx Supplementary Document Uploaded 2021-10-18 Repair queued
Att 1_Authorizing legislation.pdf Supplementary Document Uploaded 2021-10-18 Repair queued
SSB_AIMS_092921.docx Supporting Statement B Uploaded 2021-10-15 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
249805 Post-Consultation Questionnaire Form and Instruction New
249803 Peer-to-Peer Clinician Consultation [Provider Participants] Form and Instruction New
249797 Peer-to-Peer Clinician Consultation [HIV Expert Consultants] Form and Instruction New
249796 Phase II Interview for Participants of Patient-level Intervention Form and Instruction New
249793 Phase I Interview for Participants of Patient-level Intervention Form and Instruction New
249772 PositiveLinks Verbal Consent and Enrollment Form and Instruction New
249771 HIPAA Authorization [Control Patient Participants] Form New
249770 HIPAA Authorization [Patients of Providers in Provider-level Intervention] Form New
249769 HIPAA Authorization [Participants of Patient-level Intervention] Form New
249768 Verbal Consent [Control Patient Participants] Form and Instruction New
249766 Verbal Consent [Patients of Providers in Provider-level Intervention] Form and Instruction New
249765 Verbal Consent [Providers] Form and Instruction New
249764 Verbal Consent [Participants of Patient-level Intervention] Form and Instruction New
ICR Details
202109-0920-005
Received in OIRA
HHS/CDC 0920-21GH
Using Real-time Prescription and Insurance Claims Data to Support the HIV Care Continuum
New collection (Request for a new OMB Control Number)   No
Regular 10/19/2021
  Requested Previously Approved
36 Months From Approved
935 0
256 0
6,908 0
This information collection request supports the "Antiretroviral Improvement Among Medicaid Enrollees" (AIMS) study. The study will evaluate the efficacy of a Data-to-Care strategy that uses timely administrative insurance and prescription claims (billing) data to identify and intervene upon persons with HIV who fail to fill antiretroviral (ARV) prescriptions, before those individuals are lost to care. The intervention includes educational and referral resources for persons with HIV and health care providers.
US Code: 42 USC 241 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  86 FR 36550 07/12/2021
86 FR 57831 10/19/2021
No
  Total Request 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 935 0 0 935 0 0
Annual Time Burden (Hours) 256 0 0 256 0 0
Annual Cost Burden (Dollars) 6,908 0 0 6,908 0 0
Yes
Miscellaneous Actions
No
This is a new, one-time information collection request.
$709,235
Yes Part B of Supporting Statement
    Yes
    No
No
No
No
No
Renita Macaluso 770 488-6458 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/19/2021