Information Collection

Evidence Based Telehealth Network Program Report

IC 237633 under ICR 202311-0906-001 · OMB 0906-0043.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Evidence Based Telehealth Network Program Report	Form and Instruction
RTRC Study Protocol for EB TNP Data Collection - 10.20.2023.pdf	Instruction
RTRC Study Protocol for EB TNP Data Collection - 10.20.2023.pdf	Instruction
D-TEC Tool RedCap Screenshots 10.20.2023.pdf	Other-Supplemental
D-TEC Tool RedCap Screenshots 10.20.2023.pdf	Other-Supplemental
1 RTRC Data Element Dictionary RTRC Data Element Dictionary for EB TNP Data Collection - 10.20.2023.pdf	Form and Instruction
1 RTRC Data Element Dictionary RTRC Data Element Dictionary for EB TNP Data Collection - 10.20.2023.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	RTRC Data Element Dictionary	RTRC Data Element Dictionary for EB TNP Data Collection - 10.20.2023.pdf	Yes	Yes	Fillable Fileable
Instruction			RTRC Study Protocol for EB TNP Data Collection - 10.20.2023.pdf	Yes	Yes	Fillable Fileable
Other-Supplemental			D-TEC Tool RedCap Screenshots 10.20.2023.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11

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	Previously Approved
Annual Number of Responses for this IC	44	-124	168
Annual IC Time Burden (Hours)	1,364	-484	1,848
Annual IC Cost Burden (Dollars)	0	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.