Information Collection

Telehealth Satisfaction at MSSM

IC 239432 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0953 Telehealth Satisfaction at MSSM	Form and Instruction
0920-0953 TMH QA Questionnaire TMH QA Questionnaire11-25-19 mod-other dwelling.docx	Form and Instruction
OMB Fast Track Submission__MSSM_telehealth_011419 final.docx Fast Track Submission Template	IC Document

IC Title:

Telehealth Satisfaction at MSSM

Agency IC Tracking Number:

0920-0953-20GI

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	0920-0953	TMH QA Questionnaire	TMH QA Questionnaire11-25-19 mod-other dwelling.docx		No		Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	100	100
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Submission Template	OMB Fast Track Submission__MSSM_telehealth_011419 final.docx	01/24/2020

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