Information Collection

Application - THGP

IC 271205 under ICR 202409-2900-010 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-395 Application - THGP	Form and Instruction
10-395 Application Application_Telehealth Grant Program_draft.docx	Form and Instruction
10-395 Application Application_Telehealth Grant Program_draft.docx	Form and Instruction

IC Title:

Application - THGP

Agency IC Tracking Number:

VHA-2900-NEW

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 and Instruction	10-395	Application	Application_Telehealth Grant Program_draft.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 34VA12

FR Citation: 86 FR 33015

Number of Respondents: 65

Number of Respondents for Small Entity: 65

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	65	65
Annual IC Time Burden (Hours)	1,625	1,625
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.