OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Business or other for-profit

IC 241110 under ICR 202504-3060-005 · OMB 3060-1271.

Documents and Forms
Document Name
Document Type
Form
Form
Form
Form
Instruction
Instruction
Instruction
Instruction
Form
Form
Form
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Business or other for-profit WCB
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form N/A COVID-19 Telehealth Program Application Form COVID-19 Telehealth Program Application.pdf Yes Yes Fillable Fileable Signable
Instruction COVID-19 Telehealth Program Application Filing Instructions.pdf Yes Yes Fillable Printable
Form N/A COVID-19 Telehealth Request for Reimbursement Form Request for Reimbursement Form.pdf Yes Yes Fillable Fileable Signable
Instruction Request for Reimbursement Filing Instructions.pdf Yes Yes Fillable Printable
Form N/A Post-Commitment Request Form Post-Commitment Request Form (Sept 2024).pdf Yes Yes Fillable Fileable Signable

Health Health Care Services

 

2,403 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 11,517 0 0 0 0 11,517
Annual IC Time Burden (Hours) 65,929 0 0 0 0 65,929
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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