Information Collection

Telehealth Performance Measurement Report

IC 237634 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⚠️ Notice: This information collection may be referencing outdated material.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 2 Telehealth Performance Measurement Report	Form
2 Telehealth Performance Measurement Report.docx FORM_Telehealth Performance Measurement Report.docx	Form
2 FORM_Telehealth Performance Measurement Report RESPONSE FORM_Telehealth Performance Measurement Report RESPONSE CLEAN.docx	Form

IC Title:

Telehealth Performance Measurement 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	2	FORM_Telehealth Performance Measurement Report RESPONSE CLEAN.docx	FORM_Telehealth Performance Measurement Report RESPONSE CLEAN.docx		Yes	Yes	Fillable Fileable
Form	2	Telehealth Performance Measurement Report.docx	FORM_Telehealth Performance Measurement Report.docx		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	14	14
Annual IC Time Burden (Hours)	70	70
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.