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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Telehealth_Survey_VA_Form_10-04811.pdf Survey is submitted through patients' Home Telehealth Device Other-Electronic Survey Questions
PatientSatisfactionSurvey (2).doc Patient Satisfaction Survey IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.