Information Collection

State, Local or Tribal Governments

IC 241111 under ICR 202206-3060-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.