Telehealth Store and Forward Result

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

Documents and Forms

Document Name Document Type
Form 2900-0876 Teleheal Telehealth Store and Forward Result Form and Instruction
Form 2900-0876 Teleheal Telehealth Store and Forward Result Form and Instruction
2900-0876 Teleheal 2900-0876 Telehealth Store and Forward Result Wireframe Telehealth Store & Forward Result Survey UPDATED.docx Form and Instruction
2900-0876 Teleheal 2900-0876 Telehealth Store and Forward Result Wireframe Telehealth Store & Forward Result Survey UPDATED.docx Form and Instruction
ICR Template_A11 Section 280 Clearance Telehealth SFT.pdf Telehealth Store and Forward Result IC Document
ICR Template_A11 Section 280 Clearance Telehealth SFT.pdf Telehealth Store and Forward Result IC Document

Information Collection (IC) Details

IC Title:	Telehealth Store and Forward Result	Agency IC Tracking Number:	2900-0876 SFT Visit

IC Status: Unchanged

Obligation to Respond: Voluntary

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	2900-0876 Telehealth Store and Forward Result	2900-0876 Telehealth Store and Forward Result	Wireframe Telehealth Store & Forward Result Survey UPDATED.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	6,667	6,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Telehealth Store and Forward Result	ICR Template_A11 Section 280 Clearance Telehealth SFT.pdf	03/26/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.