Information Collection

Clinical Innovation Study: Telehealth in the PADRECC: The Key to the Patient-Centered Medical Home? Survey Component

IC 212916 under ICR 201409-2900-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10135a Clinical Innovation Study: Telehealth in the PADRECC: The Key to the Patient-Centered Medical Home? Survey Component	Form and Instruction
10-10135a GDS VA Form 10-10135a Telehealth in PADRECC.pdf	Form and Instruction
10-10135b PDQ-8 VA Form 10-10135b Telehealth in PADRECC.pdf	Form and Instruction
10-10135c Cost & patient outcomes questions VA Form 10-10135c Telehealth in PADRECC.pdf	Form and Instruction
10-10135d Patient Assessment of Communication during Telehealth VA Form 10-10135dTelehealth in PADRECC.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	Available Electronically?	Electronic Capability
Form and Instruction	10-10135a	GDS	VA Form 10-10135a Telehealth in PADRECC.pdf	No	Paper Only
Form and Instruction	10-10135b	PDQ-8	VA Form 10-10135b Telehealth in PADRECC.pdf	No	Paper Only
Form and Instruction	10-10135c	Cost & patient outcomes questions	VA Form 10-10135c Telehealth in PADRECC.pdf	No	Paper Only
Form and Instruction	10-10135d	Patient Assessment of Communication during Telehealth	VA Form 10-10135dTelehealth in PADRECC.pdf	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	140	140
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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