Telehealth Performance Measurement Report

Evidence Based Telehealth Network Program Measures

Documents and Forms

Document Name Document Type
Form 1 Telehealth Performance Measurement Report Form and Instruction
1 Evidence-Based Telehealth Network Program_Data Dictionar EB-TNP-PIMS-Data-Dictionary Clean.pdf Form and Instruction
1 Evidence-Based Telehealth Network Program_Data Dictionar EB-TNP-PIMS-Data-Dictionary Clean.pdf Form and Instruction
1.1 EP TNP PIMS Template EB TNP PIMS Clean Template Pending OMB Approval 10.20.2023.pdf Form and Instruction
1.1 EP TNP PIMS Template EB TNP PIMS Clean Template Pending OMB Approval 10.20.2023.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Telehealth Performance Measurement Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	1	Evidence-Based Telehealth Network Program_Data Dictionary	EB-TNP-PIMS-Data-Dictionary Clean.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	1.1	EP TNP PIMS Template	EB TNP PIMS Clean Template Pending OMB Approval 10.20.2023.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	11	-3	14
Annual IC Time Burden (Hours)	55	-15	70
Annual IC Cost Burden (Dollars)	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.