Behavioral Health Integration (BHI) Evidence Based Telehealth Network Program (EB-TNP) Measures

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2 Patient Travel Miles Saved	Form and Instruction	New	Available
Form 1 Evidence Based Telehealth Network Program (EB-TNP) Outcome Measurement Report	Form and Instruction	New	Available
Form 1 BHI EB–TNP Outcome Measurement Report	Form and Instruction	New	Repair queued
OMB-OAT-BHI DCPaaS metrics_Supporting Statement A_3-3-2025.docx	Supporting Statement A	Uploaded 2025-06-03	Available
OMB-OAT-BHI DCPaaS metrics_Supporting Statement A_3-3-2025.docx	Supporting Statement A	Uploaded 2025-06-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
275559	BHI EB–TNP Outcome Measurement Report	Form and Instruction	New	Patient Travel Miles Saved
275559	BHI EB–TNP Outcome Measurement Report	Form and Instruction	New	Evidence Based Telehealth Network Program (EB-TNP) Outcome Measurement Report
275559	BHI EB–TNP Outcome Measurement Report	Form and Instruction	New

ICR Details

OMB Control No: 0906-0109	ICR Reference No: 202506-0906-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Behavioral Health Integration (BHI) Evidence Based Telehealth Network Program (EB-TNP) Measures
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/18/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/03/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2028	36 Months From Approved
Responses	27	0	0
Time Burden (Hours)	135	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This Information Collection Request is for OMB approval of a new information collection, the Behavioral Health Integration Evidence Based Telehealth Network Program (BHI EB-TNP) Outcome Measures. Under the BHI EB-TNP, HRSA administers cooperative agreements in accordance with section 330I(d)(1) of the Public Health Service Act (42 U.S.C. 254c-14(d)(1)). The purpose of this program is to integrate behavioral health services into primary care settings using telehealth technology through telehealth networks and evaluate the effectiveness of such integration. This program supports evidence-based projects that utilize telehealth technologies through telehealth networks in rural and underserved areas to (1) improve access to integrated behavioral health services in primary care settings; and (2) expand and improve the quality of health information available to health care providers by evaluating the effectiveness of integrating telebehavioral health services into primary care settings and establishing an evidence-based model that can assist health care providers. HRSA created a set of outcome measures that focus on behavioral health to evaluate the effectiveness of grantees’ services programs and monitor their progress using performance reporting data.

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Authorizing Statute(s): US Code: 42 USC 254c-14 Name of Law: Telehealth network and telehealth resource centers grant programs
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 85545	10/28/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 23531	06/03/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
BHI EB–TNP Outcome Measurement Report	1, 2	Evidence Based Telehealth Network Program (EB-TNP) Outcome Measurement Report ,   Patient Travel Miles Saved

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	27	0	0	27	0	0
Annual Time Burden (Hours)	135	0	0	135	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $403,518

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/03/2025

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