Business or other for-profit

OMB Control No. 3060-12713

Estimated time per response: 8 hours

COVID-19 Telehealth Program Post-Program Report Template

BASIC INFORMATION

Funding Awardee Name: ______________________________________________

Participating Health Care Provider Name(s): _______________________________

Health Care Provider Number(s): ________________________________________

Funding Commitment Number: _________________________________________

Funding Commitment Amount: _________________________________________

Funding Disbursement Amount: _________________________________________

FUNDING USE

1. What connected devices and/or service(s) did you purchase and/or implement using COVID-19 Telehealth Program funding?

2. Roughly what percentage of the COVID-19 Telehealth Program funding you received was spent on connected devices? Roughly what percentage was spent on telecommunications and information services?

OUTCOMES

If relevant, please include anonymized staff, patient, and/or community accounts in response to the below questions. You may also provide any aggregated, anonymized metrics (e.g., the number of telehealth visits provided) that you tracked concerning the provision of telehealth services using COVID-19 Telehealth Program funded services or connected devices.

3. Did your staff, patients, and/or the larger community benefit from using the connected devices and/or services purchased with COVID-19 Telehealth Program funding? If so, how?

   1. Did the connected devices and/or services purchased/implemented using COVID-19 Telehealth Program funding affect health outcomes for patients? If so, how?

   2. Did the connected devices and/or services purchased/implemented using COVID-19 Telehealth Program funding help you expand your provision of telehealth services? If so, how?

   3. Did the connected devices and/or services purchased/implemented using COVID-19 Telehealth Program funding affect patient treatment protocols? If so, how?

   4. Did the connected devices and/or services purchased/implemented using COVID-19 Telehealth Program funding affect health care facility administration? If so, how?

4. What connected devices and/or service(s) purchased using COVID-19 Telehealth Program funding did you find the most useful in preventing, preparing for, or responding to COVID-19?

5. Was the COVID-19 Telehealth Program funding you received used to promote telehealth innovation? If so, how?

6. Did you use COVID-19 Telehealth Program funding to obtain services and connected devices for expanded locations beyond your traditional facilities, i.e., temporary or mobile locations set up in response to the COVID-19 pandemic? If so, please explain how these nontraditional locations assisted in preventing, preparing for, or responding to the COVID-19 pandemic.

7. Did you encounter any issues when obtaining eligible connected devices or implementing eligible services? If so, what were the issues and how did you resolve those issues?

8. Did you use all the funding awarded under the COVID-19 Telehealth Program? If not, please explain why you did not use the full award amount.

GENERAL PROGRAM FEEDBACK

9. Do you have any additional feedback about the COVID-19 Telehealth Program, the application process, and/or the invoicing process?

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FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PAPERWORK REDUCTION ACT

The public reporting for this collection of information is estimated to be up to 8 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you have any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, AMD-PERM, Paperwork Reduction Act Project (3060-1271), Washington, DC 20554. We will also accept your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to [email protected]. PLEASE DO NOT SEND YOUR RESPONSE TO THIS FORM TO THIS ADDRESS.

Remember - You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-1271.

THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

Month [2020]