Evidence Based Telehealth Network Program Measures

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Evidence-Based Telehealth Network Program_Data Dictionary	Form and Instruction	Modified	Available
Form 1 Telehealth Performance Measurement Report	Form and Instruction	Modified	Repair queued
Form 1 RTRC Data Element Dictionary	Form and Instruction	Modified	Available
Form 1 Evidence Based Telehealth Network Program Report	Form and Instruction	Modified	Repair queued
EB THNP SAT Study Protocol.pdf	Supplementary Document	Uploaded 2023-01-10	Repair queued
OMB Supporting Statement - Evidence Based Telehealth Network Program.docx	Supporting Statement A	Uploaded 2023-01-10	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
237634	Telehealth Performance Measurement Report	Form and Instruction	Modified	Evidence-Based Telehealth Network Program_Data Dictionary
237634	Telehealth Performance Measurement Report	Form and Instruction	Modified
237633	Evidence Based Telehealth Network Program Report	Form and Instruction	Modified	RTRC Data Element Dictionary
237633	Evidence Based Telehealth Network Program Report	Form and Instruction	Modified

ICR Details

OMB Control No: 0906-0043	ICR Reference No: 202301-0906-002
Status: Historical Active	Previous ICR Reference No: 201909-0906-001
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Evidence Based Telehealth Network Program Measures
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/21/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/11/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2026	36 Months From Approved
Responses	182	0	0
Time Burden (Hours)	1,918	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this program is to provide grants that demonstrate how telehealth programs and networks can improve access to quality health care services. The measures will enable OAT to capture awardee-level data that illustrates the impact and scope of federal funding along with assessing these efforts. The respondents are award recipients of the Evidence Based Telehealth Network Program.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 64060	10/21/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 1237	01/09/2023
Did the Agency receive public comments on this ICR? No

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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	RTRC Data Element Dictionary
Telehealth Performance Measurement Report	1	Evidence-Based Telehealth Network Program_Data Dictionary

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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	0	0	182
Annual Time Burden (Hours)	1,918	0	0	0	0	1,918
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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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? No

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Common Form ICR:  No

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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: 01/11/2023

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