State, Local or Tribal Governments

Promoting Telehealth for Low-Income Consumers; COVID-19 Telehealth Program

OMB: 3060-1271

IC ID: 241111

Information Collection (IC) Details

View Information Collection (IC)

State, Local or Tribal Governments WCB
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-COVID-19, Telehealth Program, LOA Attachment 5 - COVID-19 Telehealth Program Sample Letter of Authorization (002).pdf Yes Yes Fillable Printable
Form FCC Form 461 Request for Services Attachment 6 - Request for Services - FCC Form 461 (8.17).docx Yes Yes Fillable Fileable Signable
Form FCC Form 462 Request for Funding Attachment 7 - Request for Funding - FCC Form 462 (8.17).docx Yes Yes Fillable Fileable Signable
Form FCC Form 463 Description of Request for Funding Disbursement Attachment 8 - Description of Request for Funding Disbursement 8.17 - FCC Form 463.docx Yes Yes Fillable Fileable Signable

Health Health Care Services

 

2,433 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 11,541 0 2,201 0 0 9,340
Annual IC Time Burden (Hours) 66,116 0 8,341 0 0 57,775
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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