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
Form N/A Post-Commitment Request Form
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
Total burden requested under this ICR: 34553 197787 0  
To view an IC, click on IC Title