Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Business or other for-profit Modified 11517 65929 0 Form N/A COVID-19 Telehealth Program Application Form
Instruction
Form N/A COVID-19 Telehealth Request for Reimbursement Form
Instruction
Other-Post Program Report Template
Federal Government Modified 11518 65929 0 Form FCC Form 460 Description of Eligibility and Registration
Other-CMHC Checklist
Instruction
Other-Connected Care Pilot Program Questionnaire
Other-COVID-19 Telehealth Program Post-Program Report Template
State, Local or Tribal Governments Modified 11518 65929 0 Other-COVID-19, Telehealth Program, LOA
Form FCC Form 461 Request for Services
Form FCC Form 462 Request for Funding
Form FCC Form 463 Description of Request for Funding Disbursement
Other-Telecom Program Invoice
Total burden requested under this ICR: 34553 197787 0  
To view an IC, click on IC Title