Information Collection

Clinic Based Telehealth Satisfaction Survey

IC 219448 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⚠️ Notice: This information collection may be referencing outdated material.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 10-0481a Clinic Based Telehealth Satisfaction Survey	Form and Instruction
10-0481a VA Telehealth Patient Survey VA Telehealth Patient Survey_011916.docx	Form and Instruction
Generic Clearance Submission Template_CBT Patient Satisfaction Survey.doc Generic Clearance Request	IC Document
CVT Statistical Supplemental.doc CVT Statistical Methods	IC Document
White Paper - 011216.docx White Paper	IC Document
SENT_VE_Non_Substantial_Change_White Paper 12 28 15 _ Final - 1.4.16.docx VE White Paper	IC Document

IC Title:

Clinic Based Telehealth Satisfaction Survey

Agency IC Tracking Number:

2900-0770

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
Form and Instruction	10-0481a	VA Telehealth Patient Survey	VA Telehealth Patient Survey_011916.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

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	10,000	10,000
Annual IC Time Burden (Hours)	2,500	2,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Clearance Request	Generic Clearance Submission Template_CBT Patient Satisfaction Survey.doc	06/29/2016
CVT Statistical Methods	CVT Statistical Supplemental.doc	12/31/2015
White Paper	White Paper - 011216.docx	01/12/2016
VE White Paper	SENT_VE_Non_Substantial_Change_White Paper 12 28 15 _ Final - 1.4.16.docx	02/16/2016

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