Information Collection

Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire

IC 243427 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⚠️ Notice: This information collection may be referencing outdated material.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 Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire	Form
0920-0953 Telehealth Services Satisfaction Questionnaire MSSM_Telehealth_063020.docx	Form
OMB Fast Track Submission__After Visit Survey_070120 final.docx Fast Track Submission Template	IC Document

IC Title:

Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire

Agency IC Tracking Number:

0920-0953-20QI

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	0920-0953	Telehealth Services Satisfaction Questionnaire	MSSM_Telehealth_063020.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,800	3,800
Annual IC Time Burden (Hours)	63	63
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__After Visit Survey_070120 final.docx	09/01/2020

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