3 Diabetes

For each document (form/instrument) submitted, please provide the following information:

Title for this form/instrument: Performance Improvement Measurement System for the Office for the Advancement of Telehealth

1. What is the obligation to respond to this document:

1. Required to obtain or retain benefits – when the response is elective but is required to obtain or retain a benefit.

2. Frequency of reporting on this document:

1. Semi-annually

3. What are the electronic capabilities to this document:

1. Fillable & printable

4. What is the document type:

1. Form

5. Total number of respondents expected for this document annually:

21

6. Number of small entity respondents for this form/instrument:

21

7. Estimated percent of respondents who can submit electronically: 100%

8. Affected Public (who are the respondents to this form/instrument):

1. Private Sector (specify which of the following: business or other for-profits, not-for-profit institutions, farms)

9. Number of responses to this document per respondent per year:

42

10. Respondents’ burden time (in hours or fraction of hours) for reporting or responding to this document:

7