Information Collection

Business or other for-profit

IC 241110 under ICR 202012-3060-017 · OMB 3060-1271.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-1271 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Business or other for-profit	Form
Attachment 2 - COVID-19 Telehealth Program Application Filing Instructions 8.17.pdf	Instruction
Attachment 4 - COVID-19 Telehealth Program Request for Reimbursement Filing Instructions (002).pdf	Instruction
C-19 Post-Program Report Template 12.31.20_clean version.docx	Other-Post Program Report Template
COVID-19 Telehealth Program Application Form Attachment 1 - COVID-19 Telehealth Program Application Form 8.20 (003) (1).pdf	Form
COVID-19 Telehealth Request for Reimbursement Form Attachment 3 covid-19-telehealth-request-for-reimbursement-form 8.20 (002).pdf	Form

IC Title:

Business or other for-profit

Agency IC Tracking Number:

WCB

Is this a Common Form? No

IC Status: Modified

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	COVID-19 Telehealth Program Application Form	Attachment 1 - COVID-19 Telehealth Program Application Form 8.20 (003) (1).pdf	Yes	Yes	Fillable Fileable Signable
Instruction			Attachment 2 - COVID-19 Telehealth Program Application Filing Instructions 8.17.pdf	Yes	Yes	Fillable Printable
Form	N/A	COVID-19 Telehealth Request for Reimbursement Form	Attachment 3 covid-19-telehealth-request-for-reimbursement-form 8.20 (002).pdf	Yes	Yes	Fillable Fileable Signable
Instruction			Attachment 4 - COVID-19 Telehealth Program Request for Reimbursement Filing Instructions (002).pdf	Yes	Yes	Fillable Printable
Other-Post Program Report Template			C-19 Post-Program Report Template 12.31.20_clean version.docx	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,433

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	Previously Approved
Annual Number of Responses for this IC	11,541	11,541
Annual IC Time Burden (Hours)	66,115	66,115
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.