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Business or other for-profit
Promoting Telehealth for Low-Income Consumers; COVID-19 Telehealth Program
OMB: 3060-1271
IC ID: 241110
OMB.report
FCC
OMB 3060-1271
ICR 202012-3060-011
IC 241110
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-1271 can be found here:
2022-06-23 - Revision of a currently approved collection
2021-02-04 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Business or other for-profit
Form
Attachment 2 - COVID-19 Telehealth Program Application Filing Instructions 8.17.pdf
Instruction
Attachment 4 - COVID-19 Telehealth Program Request for Reimbursement Filing Instructions (002).pdf
Instruction
C-19 Post-Program Report Template 12.28.20.docx
Other-Post Program Report Template
COVID-19 Telehealth Program Application Form
Attachment 1 - COVID-19 Telehealth Program Application Form 8.20 (003) (1).pdf
Form
COVID-19 Telehealth Request for Reimbursement Form
Attachment 3 covid-19-telehealth-request-for-reimbursement-form 8.20 (002).pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Business or other for-profit
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
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
N/A
COVID-19 Telehealth Program Application Form
Attachment 1 - COVID-19 Telehealth Program Application Form 8.20 (003) (1).pdf
Yes
Yes
Fillable Fileable Signable
Instruction
Attachment 2 - COVID-19 Telehealth Program Application Filing Instructions 8.17.pdf
Yes
Yes
Fillable Printable
Form
N/A
COVID-19 Telehealth Request for Reimbursement Form
Attachment 3 covid-19-telehealth-request-for-reimbursement-form 8.20 (002).pdf
Yes
Yes
Fillable Fileable Signable
Instruction
Attachment 4 - COVID-19 Telehealth Program Request for Reimbursement Filing Instructions (002).pdf
Yes
Yes
Fillable Printable
Other-Post Program Report Template
C-19 Post-Program Report Template 12.28.20.docx
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
2,433
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
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
11,541
0
0
0
0
11,541
Annual IC Time Burden (Hours)
66,115
0
0
0
0
66,115
Annual IC Cost Burden (Dollars)
0
0
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.