Information Collection

Clinical Video Telehealth (CVT) Patient Satisfaction Survey

IC 199625 under ICR 201403-2900-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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: Modified

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
	Requested	Previously Approved
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.