Information Collection

BHI EB–TNP Outcome Measurement Report

IC 275559 under ICR 202506-0906-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 BHI EB–TNP Outcome Measurement Report	Form and Instruction
Form 1 Evidence Based Telehealth Network Program (EB-TNP) Outcome Measurement Report BHI EB–TNP Outcome Measurement Report	Form and Instruction
Form 2 Patient Travel Miles Saved BHI EB–TNP Outcome Measurement Report	Form and Instruction
1 Evidence Based Telehealth Network Program (EB-TNP) Outco BHI EB TNP DCPaaS measures_approved 5-23-25_FINAL.docx	Form and Instruction
1 Evidence Based Telehealth Network Program (EB-TNP) Outco BHI EB TNP DCPaaS measures_approved 5-23-25_FINAL.docx	Form and Instruction
2 Patient Travel Miles Saved BHI-EB DCPaaS Form 5_Modernization Measures Patient Travel Miles Saved_OAT-OGC approved 3-3-2025_FINAL.docx	Form and Instruction
2 Patient Travel Miles Saved BHI-EB DCPaaS Form 5_Modernization Measures Patient Travel Miles Saved_OAT-OGC approved 3-3-2025_FINAL.docx	Form and Instruction

IC Title:

BHI EBâTNP Outcome Measurement Report

Agency IC Tracking Number:

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	1				Yes	Yes	Fillable Fileable
Form and Instruction	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 27

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	27	27
Annual IC Time Burden (Hours)	135	135
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.

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