Form Approved
OMB No. 0990-0379
Exp. Date 3/30/2021
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
BHW Program Portal Questions
1. Do you or will you personally provide some form of telehealth in your clinical practice?
Yes
No
I don’t know
2. When providing telehealth:
I am the clinician at the originating site whose patient is receiving the consult/care
I am the clinician at the distant site providing the consult/care
Other
3. What telehealth technologies do you use? (select all that apply)
Real time telehealth (e.g., video conference)
Store-and-Forward telehealth (e.g., secure email with photos or videos of patient examinations)
Remote patient monitoring
Mobile Health (mHealth)
4. What percentage of your clinical practice is/will be spent providing telehealth services?
<10%
10-25%
25-49%
50%>
I don’t know
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | HRSA |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |