Information Collection

Telehealth Satisfaction at Mt. Sinai School of Medicine (MSSM)

IC 236605 under ICR 201802-0920-007 · OMB 0920-0953.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Telehealth Satisfaction at Mt. Sinai School of Medicine (MSSM)	Form and Instruction
Telehealth Services Patient Satisfaction Questionnaire MSSM_Telehealth QA Questionnaire_6-6-19.docx	Form and Instruction
OMB Fast Track Submission__MSSM_telehealth_062119.docx Template with Justificiation for the Amended Questionnaire	IC Document

IC Title:

Telehealth Satisfaction at Mt. Sinai School of Medicine (MSSM)

Agency IC Tracking Number:

0920-19BHZ

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
Form and Instruction	n/a	Telehealth Services Patient Satisfaction Questionnaire	MSSM_Telehealth QA Questionnaire_6-6-19.docx		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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Template with Justificiation for the Amended Questionnaire	OMB Fast Track Submission__MSSM_telehealth_062119.docx	06/21/2019

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