Clinic Based Telehealth Satisfaction Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.