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OMB Control No:	ICR Reference No: 202602-0906-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Behavioral Health Integration Evidence Based Telehealth Network Program Integration Telehealth Evidence Collection Tool
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 02/09/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	26	0
Time Burden (Hours)	1,716	0
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Change Due to Agency Discretion
Annual Number of Responses	26	26
Annual Time Burden (Hours)	1,716	1,716
Annual Cost Burden (Dollars)	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 collection

Annual Cost to Federal Government: $72,824

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. Yes

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

Agency Contact: Laura Cooper 301 443-2126 lcooper@hrsa.gov

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