Telehealth Satisfaction at MSSM

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0953 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0953 Telehealth Satisfaction at MSSM Form and Instruction
0920-0953 Telehealth Satisfaction Survey TH Satisfaction Survey.DOCX Form and Instruction
OMB Fast Track Submission__MSSM_telehealth final.docx Fast Track Submission Template IC Document

Information Collection (IC) Details

IC Title:	Telehealth Satisfaction at MSSM	Agency IC Tracking Number:	0920-0953-19AEL

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	0920-0953	Telehealth Satisfaction Survey	TH Satisfaction Survey.DOCX		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Fast Track Submission Template	OMB Fast Track Submission__MSSM_telehealth final.docx	03/19/2019

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