Evidence Based Telehealth Network Program Measures

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2 Telehealth Performance Measurement Report	Form	New	Repair queued
Form 1 Evidence Based Telehealth Network Program Report	Form	New	Available
ATTACH_Published 60 Day FRN.pdf	Supplementary Document	Uploaded 2019-09-03	Available
ATTACH 3_Evidence Based Telehealth Network Program Report 4.pdf	Supplementary Document	Uploaded 2019-09-03	Available
ATTACH 2_Evidence Based Telehealth Network Program Report (3).pdf	Supplementary Document	Uploaded 2019-09-03	Available
ATTACH 1_Evidence Based Telehealth Network Program Report (2).pdf	Supplementary Document	Uploaded 2019-09-03	Available
Supporting Statement A Evidence Based Telehealth Network Program RESPONSE CLEAN.docx	Supporting Statement A	Uploaded 2019-10-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
237634	Telehealth Performance Measurement Report	Form	New
237633	Evidence Based Telehealth Network Program Report	Form	New

ICR Details

OMB Control No: 0906-0043	ICR Reference No: 201909-0906-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Evidence Based Telehealth Network Program Measures
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/05/2019
	Date Received in OIRA: 09/04/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2022	36 Months From Approved
Responses	182	0	0
Time Burden (Hours)	1,918	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The purpose of these programs are to provide grants that demonstrate how telehealth programs and networks can improve access to quality health care services in rural and frontier communities. The measures will enable FORHP to capture awardee-level data that illustrates the impact and scope of federal funding along with evaluating these efforts. The respondents would be award recipients of the Evidence Based Telehealth Network Program.

---

Authorizing Statute(s): US Code: 42 USC 912(b)), Section 711b Name of Law: SSA
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 13936	04/08/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 44903	08/27/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Evidence Based Telehealth Network Program Report	1, 1	CORRECTED PDF - FORM Evidence Based Telehealth Network Program Report ,   Evidence Based Telehealth Network Program Report.pdf
Telehealth Performance Measurement Report	2, 2	FORM_Telehealth Performance Measurement Report RESPONSE CLEAN.docx ,   Telehealth Performance Measurement Report.docx

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	182	0	0	182	0	0
Annual Time Burden (Hours)	1,918	0	0	1,918	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR so the burden has increased from zero (0).

---

Annual Cost to Federal Government: $1,984

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/04/2019

---