Information Collection

Care Coordination Home Telehealth Patient Satisfaction Survey

IC 191713 under ICR 201001-2900-003 · OMB 2900-0766.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0766 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Telehealth_Survey_VA_Form_10-04811.pdf	Other-Electronic Survey Questions
PatientSatisfactionSurvey (2).doc Patient Satisfaction Survey	IC Document

IC Title:

Care Coordination Home Telehealth Patient Satisfaction Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Electronic Survey Questions			Telehealth_Survey_VA_Form_10-04811.pdf	Survey is submitted through patients' Home Telehealth Device	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	65,600	65,600
Annual IC Time Burden (Hours)	1,640	1,640
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Patient Satisfaction Survey	PatientSatisfactionSurvey (2).doc	08/18/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.