Information Collection

Clinical Video Telehealth (CVT) Patient Satisfaction Survey

IC 199625 under ICR 201107-2900-001 · OMB 2900-0770.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0770 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-0481a Clinical Video Telehealth (CVT) Patient Satisfaction Survey	Form
VA Form 10-0481a Clinical Video Telehealth (CVT) Patient Satisfaction Sur Clinical Video Telehealth (CVT) Patient Survey_ VA Form 10-0481a.docx	Form
Request_for_Generic_Clearance_Clinical_Video_Telehealth_Survey(v2)1.docx Clinical Video Telehealth (CVT) Patient Satisfaction Survey	IC Document

IC Title:

Clinical Video Telehealth (CVT) Patient Satisfaction Survey

Agency IC Tracking Number:

2900-0770

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.8(d)

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
Form	VA Form 10-0481a	Clinical Video Telehealth (CVT) Patient Satisfaction Survey	Clinical Video Telehealth (CVT) Patient Survey_ VA Form 10-0481a.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,500

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	2,500	2,500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Clinical Video Telehealth (CVT) Patient Satisfaction Survey	Request_for_Generic_Clearance_Clinical_Video_Telehealth_Survey(v2)1.docx	10/17/2011

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