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

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⚠️ Notice: This information collection may be referencing outdated material.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 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

Information Collection (IC) Details

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:

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 %

	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

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.