Federal Government

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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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.