Information Collection

Collection of Qualitative Feedback on Telehealth.HHS.gov

IC 243803 under ICR 202012-0915-001 · OMB 0915-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Collection of Qualitative Feedback on Telehealth.HHS.gov	Form
1 Telehealth Website - Page Level - SurveyEngSpan.docx Telehealth Website - Page Level - SurveyEngSpan.docx	Form
2 Telehealth Website - Site Level - Survey EngSpan.docx Telehealth Website - Site Level - Survey EngSpan.docx	Form
FINALTelehealth Website - GENERIC - Supporting Statement.docx Supporting Statement A Generic	IC Document

IC Title:

Collection of Qualitative Feedback on Telehealth.HHS.gov

Agency IC Tracking Number:

IC Status: Unchanged

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	1	Telehealth Website - Page Level - SurveyEngSpan.docx	Telehealth Website - Page Level - SurveyEngSpan.docx		Yes	Yes	Fillable Fileable
Form	2	Telehealth Website - Site Level - Survey EngSpan.docx	Telehealth Website - Site Level - Survey EngSpan.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	200,000	200,000
Annual IC Time Burden (Hours)	1,389	1,389
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A Generic	FINALTelehealth Website - GENERIC - Supporting Statement.docx	09/28/2020

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