Information Collection

Evidence Based Telehealth Network Program Report

IC 237633 under ICR 201909-0906-001 · OMB 0906-0043.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0043 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Evidence Based Telehealth Network Program Report	Form
1 Evidence Based Telehealth Network Program Report.pdf FORM_Evidence Based Telehealth Network Program Report.pdf	Form
1 CORRECTED PDF - FORM Evidence Based Telehealth Network P Response_10_11_2019 FORM_Evidence Based Telehealth Network Program Report (1) (002).pdf	Form

IC Title:

Evidence Based Telehealth Network Program Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	1	CORRECTED PDF - FORM Evidence Based Telehealth Network Program Report	Response_10_11_2019 FORM_Evidence Based Telehealth Network Program Report (1) (002).pdf		Yes	Yes	Fillable Fileable
Form	1	Evidence Based Telehealth Network Program Report.pdf	FORM_Evidence Based Telehealth Network Program Report.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	168	168
Annual IC Time Burden (Hours)	1,848	1,848
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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