Renewal Application - THGP

Telehealth Grant Program (THGP) - AS20

Documents and Forms

Document Name Document Type
Form 10-395a Renewal Application - THGP Form and Instruction
10-395a Renewal Application Renewal Application_Telehealth Grant Program_draft.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Renewal 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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-395a	Renewal Application	Renewal 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: 50	Number of Respondents for Small Entity: 50

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.