Telehealth Satisfaction at Mt. Sinai School of Medicine (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⚠️ Notice: This information collection may be referencing outdated material.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
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

Information Collection (IC) Details

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:

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 %

	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

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.