Information Collection

Care Coordination Home Telehealth Patient Satisfaction Survey

IC 191713 under ICR 201512-2900-010 · OMB 2900-0766.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-0341 Care Coordination Home Telehealth Patient Satisfaction Survey	Form and Instruction
10-0341 VHA Telehealth Services HT Patient Satisfaction Survey VHA Telehealth Services HT Patient Satisfaction Survey with VE questions.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	10-0341	VHA Telehealth Services HT Patient Satisfaction Survey	VHA Telehealth Services HT Patient Satisfaction Survey with VE questions.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,400

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	Previously Approved
Annual Number of Responses for this IC	65,600	65,600
Annual IC Time Burden (Hours)	1,640	1,640
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.