State, Local or Tribal Governments

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

Documents and Forms

Document Name Document Type
Sample Letter of Authorization.pdf Other-COVID-19, Telehealth Program,
Sample Letter of Authorization.pdf Other-COVID-19, Telehealth Program,
Telecom Program Invoice Form.docx Other-Telecom Program Invoice
Telecom Program Invoice Form.docx Other-Telecom Program Invoice
FCC Form 461 Request for Services Request for Services - FCC Form 461.docx Form
FCC Form 461 Request for Services Request for Services - FCC Form 461.docx Form
FCC Form 462 Request for Funding Request for Funding - FCC Form 462.docx Form
FCC Form 462 Request for Funding Request for Funding - FCC Form 462.docx Form
FCC Form 463 Description of Request for Funding Disbursement Description of Request for Funding Disbursement - FCC Form 463.docx Form
FCC Form 463 Description of Request for Funding Disbursement Description of Request for Funding Disbursement - FCC Form 463.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			Sample Letter of Authorization.pdf	Yes	Yes	Fillable Printable
Form	FCC Form 461	Request for Services	Request for Services - FCC Form 461.docx	Yes	Yes	Fillable Fileable Signable
Form	FCC Form 462	Request for Funding	Request for Funding - FCC Form 462.docx	Yes	Yes	Fillable Fileable Signable
Form	FCC Form 463	Description of Request for Funding Disbursement	Description of Request for Funding Disbursement - FCC Form 463.docx	Yes	Yes	Fillable Fileable Signable
Other-Telecom Program Invoice			Telecom Program Invoice Form.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: 2,403	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	11,518	37	-60	11,541
Annual IC Time Burden (Hours)	65,929	293	-480	66,116
Annual IC Cost Burden (Dollars)	0	0	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.