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Collection of Qualitative Feedback on Telehealth.HHS.gov
Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration
OMB: 0915-0212
IC ID: 264357
OMB.report
HHS/HSA
OMB 0915-0212
ICR 202401-0915-004
IC 264357
( )
Documents and Forms
Document Name
Document Type
Form 1
Collection of Qualitative Feedback on Telehealth.HHS.gov
Form and Instruction
1 Telehealth Website - Page Level - SurveyEngSpan
Telehealth Website - Page Level - SurveyEngSpan.docx
Form and Instruction
1 Telehealth Website - Page Level - SurveyEngSpan
Telehealth Website - Page Level - SurveyEngSpan.docx
Form and Instruction
2 Telehealth Website - Site Level - Survey EngSpan
Telehealth Website - Site Level - Survey EngSpan.docx
Form and Instruction
2 Telehealth Website - Site Level - Survey EngSpan
Telehealth Website - Site Level - Survey EngSpan.docx
Form and Instruction
Telehealth Website - GENERIC - Supporting Statement FIN.docx
Original Generic Request
IC Document
Telehealth Website - GENERIC - Supporting Statement FIN.docx
Original Generic Request
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Collection of Qualitative Feedback on Telehealth.HHS.gov
Agency IC Tracking Number:
IC Status:
New
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 and Instruction
1
Telehealth Website - Page Level - SurveyEngSpan
Telehealth Website - Page Level - SurveyEngSpan.docx
Yes
Yes
Fillable Fileable
Form and Instruction
2
Telehealth Website - Site Level - Survey EngSpan
Telehealth Website - Site Level - Survey EngSpan.docx
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:
17,465
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Requested
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
17,465
0
17,465
0
0
0
Annual IC Time Burden (Hours)
99
0
99
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Original Generic Request
Telehealth Website - GENERIC - Supporting Statement FIN.docx
01/09/2024
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.