Information Collection

Telehealth Performance Measurement Report

IC 237634 under ICR 202311-0906-001 · OMB 0906-0043.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Telehealth Performance Measurement Report	Form and Instruction
Form 1 Evidence-Based Telehealth Network Program_Data Dictionary Telehealth Performance Measurement Report	Form and Instruction
Form 1.1 EP TNP PIMS Template Telehealth Performance Measurement Report	Form and Instruction
1 Evidence-Based Telehealth Network Program_Data Dictionar EB-TNP-PIMS-Data-Dictionary Clean.pdf	Form and Instruction
1 Evidence-Based Telehealth Network Program_Data Dictionar EB-TNP-PIMS-Data-Dictionary Clean.pdf	Form and Instruction
1.1 EP TNP PIMS Template EB TNP PIMS Clean Template Pending OMB Approval 10.20.2023.pdf	Form and Instruction
1.1 EP TNP PIMS Template EB TNP PIMS Clean Template Pending OMB Approval 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1				Yes	Yes	Fillable Fileable
Form and Instruction	1.1				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	11	-3	14
Annual IC Time Burden (Hours)	55	-15	70
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.

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