State, Local or Tribal Governments

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Attachment 5 - COVID-19 Telehealth Program Sample Letter of Authorization (002).pdf Other-COVID-19, Telehealth Program,
Attachment 5 - COVID-19 Telehealth Program Sample Letter of Authorization (002).pdf Other-COVID-19, Telehealth Program,
Telecom Program Invoice 2.3.21 (clean).docx Other-Telecom Program Invoice
Telecom Program Invoice 2.3.21 (clean).docx Other-Telecom Program Invoice
FCC Form 461 Request for Services Attachment 6 - Request for Services - FCC Form 461 (8.17).docx Form
FCC Form 461 Request for Services Attachment 6 - Request for Services - FCC Form 461 (8.17).docx Form
FCC Form 462 Request for Funding Attachment 7 - Request for Funding - FCC Form 462 (8.17).docx Form
FCC Form 462 Request for Funding Attachment 7 - Request for Funding - FCC Form 462 (8.17).docx Form
FCC Form 463 Description of Request for Funding Disbursement Attachment 8 - Description of Request for Funding Disbursement 8.17 - FCC Form 463.docx Form
FCC Form 463 Description of Request for Funding Disbursement Attachment 8 - Description of Request for Funding Disbursement 8.17 - FCC Form 463.docx Form
FCC Form 463 Description of Request for Funding Disbursement (FY2021+ 2021 FCC Form 463 - 2.3.21 (clean) v2.docx Form
FCC Form 463 Description of Request for Funding Disbursement (FY2021+ 2021 FCC Form 463 - 2.3.21 (clean) v2.docx Form

Information Collection (IC) Details

IC Title:	State, Local or Tribal Governments	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:

Document Type	Form No.	Form Name	Instrument File	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
Other-Telecom Program Invoice			Telecom Program Invoice 2.3.21 (clean).docx	Yes	Yes	Fillable Fileable Signable
Form	FCC Form 463	Description of Request for Funding Disbursement (FY2021+)	2021 FCC Form 463 - 2.3.21 (clean) v2.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: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	11,541	11,541
Annual IC Time Burden (Hours)	66,116	66,116
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.