Information Collection

Collection of Qualitative Feedback on Telehealth.HHS.gov

IC 265626 under ICR 202608-0906-005 · OMB 0906-0084.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Website user (page-level survey) Collection of Qualitative Feedback on Telehealth.HHS.gov	Form
Form 2 Website user (site-wide survey) Collection of Qualitative Feedback on Telehealth.HHS.gov	Form
1 Website user (page-level survey) Telehealth Website - Page Level - SurveyEngSpan.docx	Form
2 Website user (site-wide survey) Telehealth Website - Site Level - Survey EngSpan.docx	Form
Public Burden Statement.docx Public Burden Statement Draft	IC Document
Telehealth Website - Fast Track Memo 2.15.24 FINAL.docx Generic IC Memo	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Voluntary

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	1				Yes	Yes	Fillable Fileable
Form	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	6,600	6,600
Annual IC Time Burden (Hours)	48	48
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Public Burden Statement Draft		02/26/2024
Generic IC Memo		02/26/2024

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

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