Information Collection

A. V4 Telehealth Padrecc: Focus Group Component – Pact Demo Lab Visn4

IC 212917 under ICR 201409-2900-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
10-10135 S3 VISN 4 Clincal Innovations study - Wilkinson Telehealth in PADRECC clinical survey_rev11-10-2014.doc	Instruction

IC Title:

A. V4 TELEHEALTH PADRECC: FOCUS GROUP COMPONENT â PACT DEMO LAB VISN4

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			10-10135 S3 VISN 4 Clincal Innovations study - Wilkinson Telehealth in PADRECC clinical survey_rev11-10-2014.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	120	120
Annual IC Time Burden (Hours)	20	20
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.