Information Collection

Federal Government

IC 241112 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⚠️ Notice: This information collection may be referencing outdated material.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
Form FCC Form 460 Federal Government	Form
Community Mental Health Center (CMHC) Checklist.docx	Other-CMHC Checklist
Community Mental Health Center (CMHC) Checklist.docx	Other-CMHC Checklist
Connected Care Pilot Program Instructions_final version .docx	Instruction
Connected Care Pilot Program Instructions_final version .docx	Instruction
Connected Care Pilot Program Questionnaire_final version.docx	Other-Connected Care Pilot Program Q
Connected Care Pilot Program Questionnaire_final version.docx	Other-Connected Care Pilot Program Q
COVID-19 Telehealth Program Post Program Report Template.docx	Other-COVID-19 Telehealth Program Po
FCC Form 460 Description of Eligibility and Registration Description of Eligibility and Registration - FCC Form 460.docx	Form
FCC Form 460 Description of Eligibility and Registration Description of Eligibility and Registration - FCC Form 460.docx	Form

IC Title:

Federal Government

Agency IC Tracking Number:

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	FCC Form 460	Description of Eligibility and Registration	Description of Eligibility and Registration - FCC Form 460.docx	Yes	Yes	Fillable Fileable Signable
Other-CMHC Checklist			Community Mental Health Center (CMHC) Checklist.docx	Yes	Yes	Fillable Printable
Instruction			Connected Care Pilot Program Instructions_final version .docx	Yes	Yes	Fillable Printable
Other-Connected Care Pilot Program Questionnaire			Connected Care Pilot Program Questionnaire_final version.docx	Yes	Yes	Fillable Fileable Signable
Other-COVID-19 Telehealth Program Post-Program Report Template			COVID-19 Telehealth Program Post Program Report Template.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: Federal Government

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.