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Staff members at One visit this web-site Medical, a membership-based primary care company, announced this past week their buy amoxil with free samples intention to unionize. According to Workers United, a Service Employees International Union affiliate, the bargaining unit will comprise about 500 staff members, buy amoxil with free samples including customer service agents, phlebotomists, administrative workers and assistants, front desk workers and members of the virtual team. "Each of us at One Medical pours our time, talent, and energy into providing the best possible healthcare for our patients. The workers on the frontlines of delivering this care have been at the center of our organizing process," wrote members of the One Medical Workers Union Organizing Committee in buy amoxil with free samples an unsigned letter to One Medical leadership that was provided to Healthcare IT News. A Workers United representative said the committee has chosen to wait before surfacing publicly out of fear of retaliation.

"The experience of our patients is paramount in buy amoxil with free samples this effort," the letter continued. "Our union will make it possible for us to continue providing the best primary care experience our country has to offer, and to take our organization to levels previously unseen." WHY IT MATTERS buy amoxil with free samples A spokesperson for Workers United said the decision to organize stemmed from workers' displeasure with wages, workflow and job demands. For instance, said the spokesperson, staff members say they are "often misled" during the hiring process about the workload, complexity and level of responsibility the job entails. "One Medical is clear with prospective employees about the expectations of their role," said One buy amoxil with free samples Medical in response to this allegation. "We understand that all jobs come with unexpected challenges, and One Medical is committed to enhancing the way we address feedback and concerns from our team members." "We encourage team members to go to their managers or other leaders with concerns but also have a compliance hotline available for anyone who would like to raise concerns anonymously," the statement continued.

The Workers United spokesperson said that employees also felt "severely underpaid" buy amoxil with free samples for the labor done, with salaries often below the living wage in their cities. One Medical noted that all entry-level positions pay "well over minimum wage," with entry-level positions in San Francisco starting at 37% above minimum wage with structured annual compensation increases. Given San Francisco's recent minimum wage jump, that hourly rate buy amoxil with free samples would be $22.36. According to MIT's living wage calculator, the living wage in San Francisco County for a single adult buy amoxil with free samples with no children is $28. In the metropolitan area, which extends to Oakland and Hayward, it is $22.88.The difference appears to vary from market to market.Although One Medical does not list salaries for open roles on its website, a phlebotomist job opening posted on Indeed.com for Seattle reportedly pays $20 an hour â slightly over the living wage in Seattle and in King County for a single adult with no children, as calculated by MIT.

An administrative assistant position in buy amoxil with free samples Bethesda, Maryland, also posted on Indeed.com claims to pay $18 an hour. According to MIT, the living wage for Montgomery County for a single adult with no children is $19.82. "One Medical is also diligent about conducting annual compensation assessments and is dedicated to maintaining wages that are considerate of cost of living expenses in the local market," said the company buy amoxil with free samples in a statement. Organizing staff members also cited the lack of hazard pay offered to frontline workers during buy antibiotics as an issue. "One Medical, like many of its peers, did not provide hazard pay but instead took a number of different measures to address our employeesâ concerns and mitigate the risks associated with exposure to the amoxil," buy amoxil with free samples said the company.

Employees with in-person care roles were provided with personal protective equipment buy amoxil with free samples and training, said the organization. It also said it invested in safety protocols for locations and provided many individuals with accommodations, as well as giving all administrative staff a one-time bonus during the amoxil. In addition, organizers pointed to what they described as problems with One Medical's buy amoxil with free samples treatment rollout. Forbes reported earlier this year that the company had not enforced state guidelines in its initial distribution of buy antibiotics treatments in California, resulting in stress for staff. "We have taken treatment buy amoxil with free samples eligibility requirements seriously since day one of our treatment rollout.

To be sure, over time we identified areas where we couldâve done better to verify treatment eligibility, and we changed our process for determining eligibility several times to address the changing environment for treatment distribution and to respond to input from public health authorities," said One Medical in response to these claims. "One Medical values our culture of continuous improvement and has made strides to improve the way we address feedback and concerns from our team members," buy amoxil with free samples it added. "In addition to the ability for buy amoxil with free samples employees to communicate with leadership directly under an 'open door' policy, we also have an anonymous 24/7 hotline for employees to voice concerns to the compliance department." Organizing committee members say they believe the right to form a union is one that should be celebrated and encouraged. "Our goal is to have One Medical leadership recognize One Medical Workers Union. We want to buy amoxil with free samples build a relationship based on equality and mutual respect with the One Medical executive team.

This equality will come from your recognition of our union and your commitment to bargaining in good faith," said the organizers in the letter sent to leadership. The company said that it buy amoxil with free samples will not recognize a union without an election conducted by the National Labor Relations Board. "One Medical will recognize a union if our employees vote for one after having the opportunity to go through the NLRB, secret-ballot process," it said in a statement provided to Healthcare IT News. "Our leadership remains dedicated to directly engaging with our team members and listening and learning from them, so we can continue to support them in delivering exceptional buy amoxil with free samples healthcare," it said. THE LARGER TREND The buy antibiotics amoxil contributed to feelings of burnout for many workers in the healthcare industry â and, buy amoxil with free samples in some cases, employees were disappointed in their companies' responses.

Last summer, Epic Systems sparked a backlash when it announced its intention to bring most of its 10,000 employees back to its Verona, Wisconsin campus amidst the buy antibiotics crisis. The move, which was ultimately paused until mid-2021, led some employees to consider potentially unionizing â but efforts in that arena have not made any buy amoxil with free samples public progress. Meanwhile, One Medical apologized this past week after accidentally exposing hundreds of customers' email addresses.ON THE RECORD "Mutual respect will be the responsibility of all parties involved â to see all sides of each issue and make the decisions that are best for the company in its entirety," wrote organizing committee members in the letter to One Medical leadership. Kat Jercich buy amoxil with free samples is senior editor of Healthcare IT News.Twitter. @kjercichEmail.

Kjercich@himss.orgHealthcare IT News is a HIMSS buy amoxil with free samples Media publication.The U.S. Department of Health and Human Services is warning hospitals and health systems that a security vulnerability in picture archive communication systems, first discovered two years ago, is a problem that needs fixing now.WHY IT MATTERSIn 2019, cyber researchers found a flaw in some PACS that, if exploited, could expose patient data, or put networks at risk of malware according to the alert from HHS' Health Sector Cybersecurity Coordination Center, or HC3."These systems, which can be easily identified and compromised by hackers over the Internet, can provide unauthorized buy amoxil with free samples access and expose patient records," officials warned. "There continues to be several unpatched PACS servers visible and HC3 is recommending entities patch their systems immediately. Healthcare organizations are advised to review their inventory to determine if they are running any PACS systems and if so, ensure the guidance in this alert is followed."As uasound, CT, MRI and other radiology files are stored and exchanged on PACS servers, they rely on on the Digital Imaging and Communications in Medicine formatting standard.But DICOM, developed 30 years ago, is very vulnerable to exploitation, say HC3 officials â noting that researchers "identified thousands of vulnerable PACS servers" in September 2019, and that another subsequent study "found the problem to be increasing, with additional systems identified as both vulnerable and accessible via the Internet."Cybercriminals who decide to exploit those vulnerabilities could expose medical data such as "patient names, examination dates, images, physician names, dates of birth, procedure types, procedure locations and social security numbers," said HC3 officials.A DICOM-based exploit could even allow for manipulation of medical diagnoses, scan falsifications, malware deployment or sabotage, they said â enabling bad actors to "compromise connected clinical devices and laterally spread malicious code to other parts of the network undetected."As of this past month, far too many of these PACS are still left vulnerable to exploitation, HC3 warns â estimating some 130 health systems nationwide, with "8.5 million case studies, representing over 2 million patients [and] approximately 275 million images related to their exams" left open to exposure.HC3 listed some potentially vulnerable PACS devices â which it said "is not all-inclusive" â as identified by the Department of Homeland Security:Optima 520, medical imaging systems, all versionsOptima 540, medical imaging systems, all versionsOptima 640, medical imaging systems, all versionsOptima 680, medical imaging systems, all versionsDiscovery NM530c, nuclear medical imaging system, versions prior to Version 1.003Discovery NM750b, dedicated breast imaging system, versions prior to Version 2.003Discovery XR656 and Discovery XR656 Plus, digital radiographic imaging systems, all versions,Revolution XQ/i, medical imaging system, all versionsTHUNIS-800+, stationary diagnostic radiographic and fluoroscopic X-ray system, all versionsCentricity PACS Server, used to support a medical imaging archiving and communication system, all versionsCentricity PACS RA1000, used for diagnostic image analysis, all versionsCentricity PACS-IW, an integrated web-based system for medical imaging, all versions including Version 3.7.3.7 and Version 3.7.3.8Centricity DMS, data management software, all versionsDiscovery VH / Millenium VG, nuclear medical imaging systems, all versionseNTEGRA 2.0/2.5 Processing and Review Workstation, nuclear medicine workstation for displaying, archiving, and communicating medical imaging, all versionsCADstream, medical imaging software, all versionsOptima MR360, medical imaging system, all versionsGEMNet License server (EchoServer), all versionsImage Vault 3.x, medical imaging software, all versionsInfinia / Infinia with Hawkeye buy amoxil with free samples 4 / 1, medical imaging systems, all versionsMillenium MG / Millenium NC / Millenium MyoSIGHT, nuclear medical imaging systems, all versionsPrecision MP/i, medical imaging system, all versionsXeleris 1.0 / 1.1 / 2.1 / 3.0 / 3.1, medical imaging workstations, all versions.THE LARGER TRENDPACS can be hugely useful for image management, of course, leading to benefits for quality of care and, as Healthcare IT News case studies have shown, cost savings. But imaging systems need to be properly configured to work optimally, safely and securely for the health systems that deploy them.Like other species of health IT, imaging technology is routinely found to be vulnerable to security risks â this isn't the first time federal agencies have warned about connected imaging devices in recent months â and needs to be regularly monitored and assessed for the need of new threat mitigations.ON THE RECORD"PACS security begins by checking and validating connections to ensure access is limited only to authorized users," said HC3 officials, noting that systems "should be configured in accordance with the documentation that accompanies them from their manufacturer.

Internet connected systems should ensure traffic between them and physicians/patients is encrypted buy amoxil with free samples by enabling HTTPS."Furthermore, whenever possible they should be placed behind a firewall and a virtual private network should be required to access them," they added. "The vulnerabilities associated with PACS systems range from known default passwords, hardcoded credentials and lack of authentication within third party software." Twitter. @MikeMiliardHITNEmail the writer buy amoxil with free samples. Mike.miliard@himssmedia.comHealthcare IT News is a HIMSS publication.The UKâs new Health and Care Bill was buy amoxil with free samples introduced to the House of Commons today, in a bid to deliver more joined up care. However it faces criticism from independent think tanks, the Health Foundation and the Nuffield Trust for plans to make NHS England more accountable to the government.

Under the reforms, buy amoxil with free samples Integrated Care Boards (ICB) and Integrated Care Partnerships (ICP) will be responsible for bringing together local government and NHS services in England, such as social care, mental health and public health services. The Bill also includes plans for a new NHS and public health procurement regime and to improve delivery of social care services through new assurance and data sharing measures, updated legal framework to enable person-centred models of hospital discharge and increased powers for the secretary of state to make direct payments to adult social care providers.WHY IT MATTERSThe Bill plans builds on proposals in the NHS Long Term Plan to make health and care services less bureaucratic, more accountable, and more integrated in the wake of buy antibiotics.THE LARGER CONTEXT The reforms were outlined in the Queenâs speech in May following an announcement in February by former health secretary Matt Hancock.ON THE RECORDHealth secretary Sajid Javid said. ÂTo help meet demand, build a better health service and bust the backlog, we need to back the NHS, as it buy amoxil with free samples celebrates its 73rd birthday this week, and embed lessons learned from the amoxil. This will support our health and care services to be more integrated and innovative so the NHS can deliver for people in the decades to come.âSir Simon Stevens, NHS chief executive, said. ÂThis Bill contains widely buy amoxil with free samples supported proposals for integrated care, which have been developed and consulted on over recent years by the NHS itself.

They go with the grain of what our staff and patients can see is needed, by buy amoxil with free samples removing outdated and bureaucratic legal barriers to joined-up working between GPs, hospitals, and community services.âDr Jennifer Dixon, Health Foundation chief executive, said. ÂProvisions to boost integrated care have widespread support and could help improve care for patients, although the potential benefits of these changes should not be oversold. The part of the Bill giving the Secretary of State more power over the NHS is politically driven, has no clear rationale and risks taking health care backwards.âNigel Edwards, Nuffield Trust chief executive, said. ÂThere is a clear logic to the parts of this Bill that would allow the NHS to collaborate more, as it has been trying to do for years in the face of the unhelpful 2012 Health and Social Care Act. But unfortunately these changes are bundled up with new powers for politicians to control the detail of how the health service runs.

The evidence of the past suggests this may lead to worse decisions, and they will come to regret it.â.

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Farmers and people http://pupdogs.net/2015/12/20/my-last-gift-to-nina-weena-tofina/ in rural areas are more comfortable talking about stress and mental health challenges with others, and stigma around seeking help or treatment has decreased in rural and farm communities but is still a factor, according to a new research poll from the amoxil cost American Farm Bureau Federation. AFBF conducted the survey of rural adults and farmers/farmworkers to measure changes and trends in stigma, personal experiences with mental health, awareness of information about mental health resources and comfort in talking about mental health with others. The poll results were compared with previous amoxil cost surveys AFBF conducted in 2019 and 2020 focusing on farmer mental health, and the impacts of the buy antibiotics amoxil on farmer mental health, respectively. ÂFarm Bureau has been encouraging conversations to help reduce stigma around farmer stress and mental health through our Farm State of Mind campaign,â said AFBF President Zippy Duvall.

ÂThis poll shows that we are making a difference, but we all still have work to do. Itâs up to each of us to keep looking out for our family, friends and neighbors and let them know theyâre not alone when they feel the increasing stress that comes with the daily business of farming and ranching.â Morning Consult conducted the poll on behalf of AFBF in amoxil cost December 2021 among a national sample of 2,000 rural adults. Key findings include. Stigma around seeking help or treatment for mental health has decreased but is still a factor, particularly in agriculture.

Over the past year, there has been a decrease in rural adults saying their friends/acquaintances (-4%) and people in their local community (-9%) attach stigma to seeking help or treatment amoxil cost for mental health. But a majority of rural adults (59%) say there is at least some stigma around stress and mental health in the agriculture community, including 63% of farmers/farm workers. Farmers/farm workers are more comfortable talking to friends, family and their doctors about stress and mental health than they amoxil cost were in 2019. Four in five rural adults (83%) and 92% of farmers/farm workers say they would be comfortable talking about solutions with a friend or family member dealing with stress or a mental health condition, and the percentage of farmers/farm workers who say they would be comfortable talking to friends and family members has increased 22% since April 2019.

A majority of rural adults (52%) and farmers/farm workers (61%) are experiencing more stress and mental health challenges compared to a year ago, and they are seeking care because of increased stress. Younger rural adults are more likely than older rural adults to say they are experiencing more stress and mental health challenges compared to a year ago, and amoxil cost they are more likely than older rural adults to say they have personally sought care from a mental health professional. A slide deck with additional detail on the full survey results is available here. AFBF will be featuring two events focused on farmer mental health at the 103rd AFBF Convention in Atlanta, Georgia.

A panel discussion with Farm amoxil cost Bureau representatives on Sunday, Jan. 9, at 10:45 a.m. EST, and a QPR mental health training workshop conducted by AgriSafe that offers farmers and farm families amoxil cost skills to recognize and respond to mental health crises using the Question, Persuade and Refer approach, on Monday, Jan. 10, at 2:00 p.m.

EST. If you or someone you know is struggling emotionally or has concerns about their mental health, visit the Farm State of Mind website at farmstateofmind.org for information on crisis hotlines, treatment locators, tips for helping someone in emotional pain, ways to start amoxil cost a conversation and resources for managing stress, anxiety or depression. Contact. Mike TomkoDirector, Communications(202) 406-3642miket@fb.org Ray AtkinsonDirector, Communications(202) 406-3717raya@fb.org Return to NewsroomStart Preamble Federal Communications Commission.

Final rule amoxil cost. In this document, the Federal Communications Commission (Commission or FCC) requires all covered text providers to support text messaging to 988, the 3-digit dialing code to reach the National Suicide Prevention Lifeline, by July 16, 2022. Given the popularity of text messaging, particularly among at-risk populations, it is amoxil cost essential for Americans to be able to text the Lifeline with the same short, easy-to-remember code by which they will be able to call the Lifeline. This rule is effective February 4, 2022.

Start Further Info Start Printed Page 399 Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388, Michelle.Sclater@fcc.gov. End Further Info End Preamble Start Supplemental Information This is amoxil cost a summary of the Commission's Second Report and Order (SRO) in WC Docket No. 18-336, adopted on November 18, 2021and released on November 19, 2021. The document is available for download at https://docs.fcc.gov/âpublic/âattachments/âFCC-21-119A1.pdf.

To request materials in accessible formats for people with disabilities (Braille, amoxil cost large print, electronic files, audio format), send an email to FCC504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at 202-418-0530 (voice), 202-418-0432 (TTY). Synopsis I. Second Report amoxil cost and Order A.

Text-to-988 Will Save Lives 1. We conclude that amoxil cost requiring covered text providers to support text-to-988 will save lives. No commenter in the record opposes adoption of a text-to-988 requirement. As Americans become more reliant on texting to communicate, the need to access mental health assistance and resources by text is essential.

Text messaging to the Lifeline will facilitate access to critical mental health resources for all, and amoxil cost particularly for at-risk populations who tend to prefer communicating through text rather than phone calls. 2. The record reflects overwhelming support for the conclusion that text-to-988 functionality will greatly improve consumer access to the Lifeline. Over 14 National amoxil cost Alliance on Mental Illness (NAMI) offices across the United States filed in support of text messaging to 988.

Substance Abuse and Mental Health Services Administration (SAMHSA), the Government agency responsible for overseeing the Lifeline, states that texting capability would improve equitable access to the Lifeline, especially for at-risk communities. And Vibrant, the administrator of the Lifeline, also notes that âtext-to-988 capability would improve consumer accessibility to the Lifeline and save lives.â Mental Health America suggests that â[i]f 988 is implemented without support for text messaging, individuals in need of mental health crisis services, particularly amoxil cost youth and adolescents, will remain unanswered.â A bipartisan group of U.S. Representatives from Colorado express their support, stating that â[b]y allowing a text-to-988 option in addition to voice call, the Commission can lower the bar to entry and improve access to crisis counseling and mental health services.â Text-to-988 will provide greater access to anyone who is not comfortable calling the Lifeline or cannot make a phone call. For instance, individuals who are in abusive or controlling situations may feel safer texting than making a verbal call when in a crisis.

Similarly, for individuals who are helping someone who is experiencing symptoms such as paranoia or delusions and amoxil cost appears threatening, texting offers greater safety when reaching out for crisis assistance. 3. The record also demonstrates that requiring covered text providers to support text-to-988 functionality will provide significant benefits to at-risk populations, particularly to young Americans who are disproportionately at risk for mental health crises. Research shows that serious psychological distress, major depression, and suicidal thoughts amoxil cost and attempts among adolescents and young adults have increased significantly in recent years.

SAMHSA explains that individuals who send texts or online chats to the Lifeline both skew younger and are more likely to experience current suicidal ideation relative to the categories of individuals who typically access the Lifeline via phone. Nearly 95% of teens have access to smart phones and report that texting is the primary way amoxil cost by which they connect. According to Mental Health America, â[m]ultiple sources of data demonstrate youth prefer communicating by text rather than calls,â including a study finding that young people âwere more likely to forgo psychological support than talk in person or over the phone.â Nevada, which conducted one of the country's first text messaging for crisis response pilot programs, TextToday, found an increase in help-seeking behaviors by youth as a result of the program and a preference for texting among the youth age cohort. Some members of at-risk populations may prefer or find it easier to access the Lifeline via text as compared to the online chat portal, which requires people to have internet access, find the website, and locate the chat portal.

A survey amoxil cost addressing how teens are coping and connecting during buy antibiotics reported that 65% of teens used texting to communicate with friends and family more than usual in response to the amoxil. 4. In addition to young Americans, text-to-988 will help other American communities that are disproportionately impacted by suicide, including Veterans, LGBTQ+ individuals, racial and ethnic minorities, and rural Americans. Death by suicide amongst Veterans has steadily increased over the past several amoxil cost years.

Mental Health America notes that data they collected demonstrate that individuals âwho identify as Black or African American are more likely to report that they would like to receive a phone amoxil cost number they can immediately call or text for helpâ than members of any other race or ethnicity. Individuals from communities, religious groups, or ethnic backgrounds that have been found to have lower professional help-seeking behaviors or whose communities are less typically accepting of mental health treatment will also benefit from the added privacy of seeking crisis support via text. 5. Text messaging has also become a crucial form of communication for people who amoxil cost are deaf, hard of hearing, or have other disabilities that impact communication.

Studies find an increased risk of suicide among deaf and hard of hearing people when compared to those without hearing loss. These individuals have increasingly adopted widely available text messaging platforms in lieu of specialized legacy devices, such as text telephones (TTY), because of the ease of access, wide availability, and practicability of modern text-capable devices. Some individuals with disabilities find it more effective to access mental health support through text messaging over other means of communications amoxil cost. Vibrant notes that for individuals in the disability community, the ability to text crisis services directly, without need for an intermediary interpreter or service, provides âsubstantial benefit.â SAMHSA highlights the convenience texting would provide to people with autism spectrum disorder (ASD), who are at an increased risk for suicide, yet may have âdifficulties with back and forth conversations, and may therefore prefer to text rather than call the Lifeline.â Access to communications capabilities for individuals with disabilities is a longstanding Commission priority and statutory obligation.

Our requirement to support Start Printed Page 400 text-to-988 broadens access to 988 and helps ensure individuals amoxil cost with disabilities that impact communication can more easily reach lifesaving resources. 6. The Commission's designation of 988 as the 3-digit telephone number for the Lifeline reflected its expectation that a simple, easy-to-remember, 3-digit dialing code for suicide prevention and mental health crisis counseling would âhelp increase the effectiveness of suicide prevention efforts, ease access to crisis services, reduce the stigma surrounding suicide and mental health conditions, and ultimately save lives.â We conclude that providing text access at the same short code number will generate synergies that enhance the value of efforts to promote 988. We are also mindful that the promotion and availability of the 988 short code for telephone calls to the Lifeline crisis hotline, and by extension the Veterans Crisis Line, could create confusion as to whether that number amoxil cost is available for, and capable of, receiving text messages.

We find that requiring providers to implement text-to-988 will also help to avoid confusion or putting lives at risk. B. Designating a Wholly Unique 3-Digit Dialing amoxil cost Code vs. An Existing N11 7.

We adopt amoxil cost our proposed two-step process to establish the scope of text messages that fall within our text-to-988 requirement (86 FR 31404, June 11, 2021). While we acknowledge the importance of testing and coordination between covered text providers and the Lifeline, we decline at this time to adopt the Department of Veterans Affairs' (VA's) proposed âthird-stepâ to our scope of text messages because the proposed testing and validation process is not germane to ex ante defining the scope of covered text providers. First, we establish an outer bound definition of â988 text messageâ that sets the maximum possible scope of text formats which covered text providers may be obligated to support for delivery to 988, based on the definition of âtext messageâ that Congress enacted in 2018 in the Truth in Caller ID context. Second, we establish a process to ensure that covered text providers only must enable transmission of text amoxil cost messages in formats that the Lifeline can actually receive.

We also define the scope of entities subject to our text-to-988 requirementsâ i.e., âcovered text providersââto be consistent with our text-to-911 rules, which include Commercial Mobile Radio Services (CMRS) providers and providers of interconnected text messaging services. We find that this approach, in combination, provides a forward-looking, flexible scope that will expand with the capabilities of the Lifeline without unnecessarily obligating covered text providers to support formats that the Lifeline cannot yet receive. 1 amoxil cost. Scope of Covered Text Formats 8.

Outer Bound amoxil cost Definition. Consistent with our proposal in the further notice of proposed rulemaking (FNPRM) (86 FR 31404, June 11, 2021), we adopt the Truth in Caller ID definition of âtext messageââincluding the definitions for âshort message serviceâ (SMS) and, as a requirement when Lifeline is able to support it, âmultimedia message serviceâ (MMS)âas the outer bound scope of text messages that covered text providers may be obligated to transmit to 988, which provides that the term (1) means a message consisting of text, images, sounds, or other information that is transmitted to or from a device that is identified as the receiving or transmitting device by means of a 10-digit telephone number or N11 service code. (2) includes a SMS message and a multimedia message service (commonly referred to as `MMS') message. And (3) does not includeâ(i) a real-time, two-way voice or video communication amoxil cost.

Or (ii) a message sent over an internet protocol (IP)-enabled messaging service to another user of the same messaging service, except a message described in clause (2). 9. We find amoxil cost that there are several advantages to adopting the Truth in Caller ID definition in the text-to-988 context. The definition encompasses, but is not exclusive to, SMS and MMS messages without limiting the outer bounds of supported text formats to specific technologies, thus providing flexibility for inclusion of future text message formats under the rules.

It also represents a recent definition provided by Congress, albeit in a different policy context. We slightly modify the Truth in Caller ID definition to account for the 988 context by adopting our proposal to add âor 988â to the phrase from the Truth amoxil cost in Caller ID definition â10-digit telephone number or N11 service code.â This modification will ensure that covered text providers' obligations encompass those text messages sent to the Lifeline via the 3-digit code 988. We also add language clarifying that the definition we adopt âincludes and is not limited toâ SMS and MMS messages. This addition clarifies that the word âincludes,â within the definition we adopt, does not amoxil cost limit the scope of messages meeting the first prong of the definition and instead merely eliminates doubt as to whether SMS and MMS meet that definition.

This clarification advances our policy goal of promoting availability of a broad range of communications methodologies for individuals reaching the Lifeline. Further, we think this clarification follows the canon of avoiding rendering language a nullityâif the definition included only SMS and MMS, the first provision would be unnecessary. 10. We decline to adopt the text-to-911 text message definition, as recommended by CTIA and T-Mobile.

The Truth in Caller ID definition is more recent than the text-to-911 text message definition, and it derives from Congress. The Truth in Caller ID definition expressly identifies that it includes images and sound. Allowing the parties that operate the Lifeline to incorporate graphics or other rich media in addition to textual communications, if they choose to do so, offers members of at-risk communities the means to communicate flexibly and fully with the Lifeline. Furthermore, the limitation of the initial implementation requirement to SMS messages, as discussed below, addresses CTIA and T-Mobile's concerns about meeting the implementation deadline if the Commission were to immediately require implementation of other text formats.

The annual review process we establish below, through which the Wireline Competition Bureau (Bureau) will require covered text providers to implement only those texting formats within the outer bound definition that the Lifeline can actually receive, will ensure that covered text providers are not burdened with unnecessary work, and will avoid any consumer confusion that would arise from implementing formats that cannot go through. 11. We clarify that the exclusions we adopt from the â988 text messageâ definition match those exclusions contained in the Truth in Caller ID âtext messageâ definition. We therefore exclude âreal-time, two-way voice or video communication[s],â as well as messages sent over âIP-enabled messaging service[s] to another user of the same messaging serviceâ that are not SMS or MMS messages.

Similar to the Commission's interpretation in the Truth in Caller ID Second Report and Order (84 FR 45669, August 30, 20219), we conclude that âreal-time, two-way voice or video communicationâ includes voice calling service. We find that the plain language of the Truth in Caller ID exclusion indicates that Congress explicitly intended to exclude real-time, two-way video communication from the definition of âtext message. We further âinterpret the latter exclusion to include non-MMS or SMS messages sent using IP-enable Start Printed Page 401 messaging servicesâ between users of the same service. For example, a message transmitted via an application delivered over IP-based networks, such as Twitter or LinkedIn, to another user of the same messaging service would be excluded from the outer bound definition.

12. We decline the Consumer Electronics Association's (CEA's) request to affirmatively determine at this time what particular text messaging formats fit within the outer bound definition. We direct the Bureau to resolve questions concerning the scope of the outer bound during the annual review process by applying the statutory Truth in Caller ID definition and Commission precedent regarding that definition. We clarify that should the Bureau find in the future based on the record before it that rich communications service (RCS), real-time text (RTT), or other formats do not fall within the exclusions from the 988 text message definition, then they may be acceptable formats within the outer bound scope.

We adopt the proposed procedure delegating to the Bureau future determinations to require covered text providers to support additional text formats within the outer bound definition, in consultation with our Federal partners and in consideration of what text formats the Lifeline is capable of receiving. We therefore define âcovered 988 text messageâ as a 988 text message in SMS format and any other format that the Wireline Competition Bureau has determined must be supported by covered text providers. 14. The record supports requiring transmission of texts to 988 in SMS format.

Vibrant indicates that the Lifeline can currently receive and respond to SMS messages sent to the 10-digit number. Furthermore, representatives of covered text providers and public interest groups express support for requiring transmission of SMS messages to 988. In their support for adoption of requirements based on the Commission's text-to-911 rules, CTIA and T-Mobile note the technical feasibility of supporting SMS messages to 988, given that that format is currently supported in texting to 911. CEA also argues that the Commission should, at a minimum, require transmission of text messages in SMS within its broader outer bound definition.

Because there is no technical or operational impediment to transmitting SMS messages to 988 expressed by covered text providers, and the Lifeline is currently able to receive and respond to SMS messages, we require covered text providers to support SMS messages to 988. 15. We decline at this time to require covered text providers to support other text message formats, such as MMS, RCS, and RTT, because the Lifeline cannot currently receive texts in these formats. The Bureau will consider requiring covered text providers to support these or other additional formats through the Public Notice process we discuss below, should the Lifeline indicate it can receive such formats.

While commenters note that rich media communications and next-generation text formats may offer benefits to individuals attempting to access the Lifeline, requiring covered text providers to transmit messages in these formats is premature because we do not know if or when the Lifeline will accept these formats. In addition, as CTIA states, including additional text formats such as RTT and RCS in the scope of our text-to-988 requirements âwould cause consumer confusion when the Lifeline is only capable of receiving SMS messages todayâ and, due to technical and engineering obstacles, would likely delay implementation of text-to-988 service. Finally, with respect to multimedia messages, both the Alliance for Telecommunications Industry Solutions (ATIS) and CTIA note that including media in text messages, a feature not currently supported in text-to-911 service, would present technical obstacles that could impede implementation by the July 16, 2022, deadline that we adopt. Although Vibrant indicates that the Lifeline is technically capable of receiving MMS formats, it clarifies that Lifeline policy and clinical standards âcurrently block[â] images and video from being seen by the counselor.â Because of the impediments to transmitting media such as images and video with text to 988, we decline to require covered text providers to support MMS messages to 988.

We further direct the Bureau, on or before June 30, 2023, and no less frequently than annually thereafter, to propose and seek comment on implementation parameters for covered text providers to transmit any additional text message formats to 988 that the Lifeline is capable of receiving and that are within the scope of the outer bound message definition adopted herein. The Bureau shall identify the additional text messaging format(s) that the Lifeline is capable of receiving, if any. Propose and seek comment on an interpretive determination as to whether the additional text message format(s) fall within the outer bound definition. And propose and seek comment on implementation deadline(s) for those additional text message formats.

If the Bureau finds after this process that the Lifeline is capable of receiving an additional text format that is within the scope of the outer bound definition that we have established, it shall release a second Public Notice requiring covered text providers to implement text-to-988 using that new format and setting an implementation date that is as prompt as reasonably practical. If the Bureau instead finds that, notwithstanding its initial proposal, the Lifeline is not capable of receiving an additional text format that is within the scope of the outer bound that we have established, it shall issue a Public Notice declining to adopt its initial proposal. The Bureau may set one implementation deadline or staggered implementation deadlines for different classes of providers, and it shall identify all implementation deadlines with certainty ( i.e., by a specified calendar date). In setting a deadline or deadlines for compliance, the Bureau shall assess factors such as technical and financial challenges with respect to implementation, the status of the Lifeline, and the public interest.

We find our two-step approach allows us to ensure rapid support for additional texting formats as technology evolves, while providing certainty to the industry and the public. Further, we find this approach facilitates further updates when the Lifeline implements a new texting format without requiring a Commission rulemaking, which often requires more time than Bureau-level action. Accordingly, we direct the Bureau to implement the approach we describe above, including through prescribing implementation deadlines. Start Printed Page 402 17.

CEA supports the Commission's proposal but asks for the Bureau to conduct annual public hearings rather than develop a written record. We find the proposed Public Notice procedure achieves the same purpose as a public hearingâproviding a forum to establish a record regarding expansion of the covered 988 text message definitionâwhile imposing fewer administrative burdens and costs on the public and the Commission. We expect the Bureau to meet with interested parties, as permitted by the Commission's ex parte rules. 18.

We decline to adopt CEA's proposals to bypass our Public Notice procedure and automatically include MMS, RCS, or RTT within the scope of covered 988 text messages if and when the Lifeline is ready to accept those new texting formats. We think the Public Notice process is valuable because it will allow the Bureau to gather information to set appropriate technology-specific implementation deadlines and to evaluate whether a given technology fits within the outer scope of the definition of 988 text message we adopt herein. It also provides the Bureau time to facilitate dialogue between parties should any complications arise. We are concerned that automatic inclusion of certain formats in the future could lead to avoidable problems, and we therefore decline CEA's suggestion.

19. We also decline CEA's proposal that, should the Bureau or Commission require inclusion of RCS, RTT, or any other format, covered text providers would be required to support the new format âby the later of (i) three months after the Lifeline states that it is ready to receive such format. Or (ii) the date upon which the affected covered text provider begins providing such texting format to its customers generally.â We find it best to grant the Bureau flexibility to determine an implementation timeframe appropriate to each technology the Lifeline may implement. We prefer this approach because the Bureau will be able to make a decision based on a thorough record focused on the Lifeline's actual implementation of the technology.

We anticipate that some technologies such as RTT that are already generally in use may be easier for covered text providers, especially larger providers, to support if implemented by the Lifeline, and we encourage the Bureau to take ease of implementation and availability of the technology into account when reaching a determination. 20. We decline requests from CEA and ZP Better Together (ZP) to require direct video communication (DVC) and direct dialing from video relay service (VRS) to 988. With respect to VRS, ZP believes that by dialing 988 directly, both a Lifeline counselor and a VRS communications assistant would show up simultaneously.

We are not addressing ZP's VRS request at this time because direct 988 dialing for VRS is beyond the scope of this item, which is focused on text-to-988. With respect to DVC, we strongly encourage the development and implementation of direct communications solutions for individuals with disabilities. However, the Lifeline does not receive direct communications via video. Requiring providers to support communications that the Lifeline is not currently capable of receiving would cause consumer confusion, as individuals in crisis may attempt to access the Lifeline via direct video communications without realizing that the Lifeline cannot answer.

We are pleased that the Lifeline is available to users of telecommunications relay services, including via 988, and the Lifeline maintains a separate TTY number, and we encourage our Federal partners to continue to consider additional alternative means by which individuals with disabilities may contact the Lifeline. Users of speech-to-speech services and TTY-based TRS dial 711 first to connect to a communications assistant who will complete the call to the Lifeline. 2. Definition of âCovered Text Providerâ 21.

CTIA encourages us to keep the text-to-988 scope consistent with the scope of covered text providers in the text-to-911 context in order to âidentify a well-known and experienced scope of providers who will need to work collaboratively with the Lifeline to achieve the aggressive deadline that CTIA and others have suggested.â T-Mobile similarly agrees with CTIA that the Commission should look to its text-to-911 rules when establishing the scope of covered text providers in the text-to-988 context. And, as CTIA notes, no commenter suggests an alternative definition to our proposal. 23. We require interconnected text messaging service providers, which enable customers to âsend text messages to all or substantially all text-capable U.S.

Telephone numbers and receive text messages from the same,â to support text-to-988 service. We decline to apply our requirements to non-interconnected text providers, as CEA suggests. By definition, non-interconnected text providers cannot send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, meaning they are unlikely to be able to transmit texts to and receive texts from 988.

Even non-interconnected text providers that use telephone numbersâfor instance where an application uses telephone numbers to identify users relative to each other rather than for routingâmay nonetheless be unable to send text messages to users of other services or to all or substantially all telephone numbers. Obligating non-interconnected text providers to attempt to route texts to 988 via telephone numbers when physical routing is beyond such providers' control could increase customer confusion or diminish public trust in texting as a means to reach the Lifeline. 24. Voice on the Net (VON) and Mitel request that we exempt covered text providers in Wi-Fi only locations because âthere remain challenges to the reliability of routing text messages to interconnected networks without the benefit of a CMRS provider.â We decline at this time to adopt a blanket exemption for covered text providers in Wi-Fi only locations.

While we anticipate interconnected text messaging service providers will typically use CMRS-based solutions to support text-to-988, CMRS networks are not the only means of interconnection, and covered text providers may use any reliable method or methods to support text routing and transmission to 988. Furthermore, neither VON nor Mitel elaborate on or provide evidence to support their claims of technical challenges associated with routing without access to a CMRS network, or that such challenges cannot be bypassed by adopting a non-CMRS solution. While we agree with Mitel that â[r]outing messages to the interconnected network often requires access to an underlying wireless network or provider,â commenters have not provided sufficient support for us to Start Printed Page 403 conclude that covered text providers in Wi-Fi only locations are never able to use a CMRS-based or alternative method to reliably support text routing and transmission to 988. We reiterate that our requirements exclude providers that are unable to allow consumers to send text messages to and receive text messages from all or substantially all text-capable U.S.

Our decision is consistent with the Commission's approach in the 988 Report and Order (85 FR 57767, September 16, 2020) to require service providers to âtransmit all calls initiated by an end user dialing 988 to the current toll free access number for the Lifeline.â Most commenters support centralized routing for text-to-988. 26. We find our centralized routing rule will allow for swift implementation of text-to-988 to the Lifeline's 10-digit number by lowering technical requirements and costs for covered text providers to route texts to the Lifeline. As Vibrant states, our centralized routing solution for text-to-988 will âallow[] for a seamless delivery of crisis intervention services that is consistent with clinical standards, best practices, and national guidelines overseen by the administrator and SAMHSA.â CTIA notes that by requiring centralized routing, âthe Commission can significantly lower technical hurdles to enable wireless providers to deploy text-to-988 as soon as possible.â ATIS âhas not identified any technical challenges associated withâ routing covered 988 texts to the Lifeline 10-digit number.

We note that several wireless providers were able to implement routing calls to 988 within six months of adoption, and we anticipate that similarly swift implementation may be possible here. 27. We also find that adopting our proposal will provide our Federal partners with the flexibility to develop and expand routing solutions to meet the Lifeline's needs. Once text messages are routed to the Lifeline's 10-digit number, the Lifeline can then âforward those messages to the appropriate local crisis center,â similar to the current mechanism for voice call routing to 988.

Currently, the Lifeline's network consists of over 180 crisis centers, with 33 centers providing text service. SAMHSA has identified resource strain and capacity issues experienced during its rollout of text service to the Lifeline's 10-digit number and, as a result, indicates its intention to explore working with existing crisis text and chat services outside the Lifeline as well as expanding text capacity within the network. We encourage SAMHSA and the VA to work with outside entities as needed to meet increased demand, and we believe our centralized routing rule will better allow for the Lifeline's network to adapt, evolve, and expand as necessary to meet capacity and technological needs. 28.

We decline to require covered text providers to route covered 988 text messages directly to a Lifeline local crisis center or Veterans Crisis Line crisis center. While text-to-911 uses such direct routing, we believe that approach would be counterproductive for text-to-988. We disagree with Intrado's proposal to leverage the existing text-to-911 infrastructure by using Intrado's Text Control Center (TCC) services to transmit texts to 988 directly to an individual local crisis center, once the crisis center has made a valid request for text-to-988 service. This proposal mirrors the text-to-911 rules, where a covered text provider must enable text-to-911 service within six months of a local Public Safety Answering Point's (PSAP's) valid request for service.

We are concerned that implementation of a localized routing model would be time-consuming, contrary to our goal of making text-to-988 rapidly available to all Americans. CTIA and T-Mobile point to specific technical and administrative challenges should the Commission require covered text providers to route texts to 988 to local crisis centers, which would compromise swift implementation by the July 16, 2022, date. ATIS, T-Mobile, and VON also note routing to the local crisis centers would require the adoption of new technical standards and specifications, including the development of intermediate gateway providers at regional centers, which could increase costs and delay launch of text-to-988. Requiring delivery of texts to 988 to individual crisis centers could impede the Lifeline network's future expansion, as covered text providers would need to implement text routing to each new center to ensure that the community served by that center can communicate via text if desired, as opposed to immediate nationwide access through centralized routing.

Furthermore, as CTIA points out, âIntrado fails to explain why texts to 9-8-8 should be routed differently from voice calls to 9-8-8.â We see no difference between voice and text service to the Lifeline presented in the record that would justify adopting alternate routing infrastructures for either service. In contrast, there are significant differences between 988 and 911, chief among them the nationwide Lifeline voice and text service routed through a centralized, toll free 10-digit number as opposed to the localized PSAP network. 29. We find that it is premature to require covered text providers to enable covered 988 text messages to include location information.

As instructed by Congress in the National Suicide Hotline Designation Act of 2020, in April 2021 the Bureau released a report on the costs and feasibility of providing location information with calls to 988. In the report, the Bureau recommended the establishment of a multi-stakeholder advisory committee to develop detailed recommendations on how to address several challenges presented in the record, including privacy considerations, technical implementation, and cost recovery. NAMI and Vibrant reiterate arguments raised in the 988 Geolocation Report that requiring geolocation information with calls and texts to local crisis centers will improve accuracy in connecting individuals in crisis with counselors who are in the best position to provide localized care. Yet, as the Bureau identified in the 988 Geolocation Report, requiring providers to transmit location information to 988 âraises important privacy and legal issues, is technically complex, and could impose significant costs.â Several commenters, including ATIS and CTIA, highlight the challenges identified in the 988 Geolocation Report and oppose a location information requirement for text-to-988, indicating it would be premature for the Commission to adopt such a mandate without further study and standards development.

Given the similar complexity and interrelation between call and text routing to 988, we decline, at this time, NAMI and Vibrant's requests to require location information with texts transmitted to 988. Commenters also raise privacy concerns should the Commission require the transmission of location information without the texter's consent. Given the Bureau's recommendation and the similar concerns raised in the record regarding technical limitations of providing location information, we decline, at the present time, to require covered text providers to include location information with texts to 988. 30.

We also decline to require covered text providers to take action to route texts to 988 to the Veterans Crisis Line, and we instead defer to our Federal partners to determine whether and how to make it possible to text 988 for the Start Printed Page 404 Veterans Crisis Line's text service. Telephone callers to the Lifeline's 10-digit number can press â1â to connect directly with a crisis counselor at the Veterans Crisis Line. Texting, on the other hand, is not presently integratedâtexters who wish to reach the Veterans Crisis Line contact a text short code (838255) rather than the Lifeline's toll free 10-digit number. We recognize that there would be significant benefits to enabling texters to reach the Veterans Crisis Line by texting 988.

At the same time, we recognize the critical need for carefully developing a pilot program and extensively testing the transfer of texts between 988 and the Veterans Crisis Line to ensure that no Service Member, Veteran, or family member is left without access to lifesaving resources. Any rush to enable texting 988 for the Veterans Crisis Line's text service before sufficient implementation work and testing would raise safety concerns, should any text conversations be dropped or lost in transfer. We believe our Federal partners at the VA and SAMHSA are best positioned to evaluate the benefits, challenges, and costs of transferring texts and to pursue a solution, if desirable. We agree with ATIS that use of 988 âmakes it infeasible to automatically route calls to one service or the otherâ without additional information, such as through a secondary input exchange, to enable providers to correctly route the text to the proper recipient.

There is no record support for Commission action to require providers to selectively route texts to 988 to the Veterans Crisis Lifeline's text service. Nor does the record reveal any solutions for requiring providers to implement texting to 988 for the Veterans Crisis Line's text service that we could effectuate in conjunction with requiring providers to implement texting to 988 for the Lifeline. After evaluation and testing, our Federal partners may be able to pursue a workable, reliable approach to enabling texts to 988 to reach the Veterans Crisis Line. At the present time, Service Members, Veterans, and their families may reach the Veterans Crisis Line by calling 1-800-273-8255 and pressing 1, by texting 838255, or by chat through the Veterans Crisis Line's website, https://www.veteranscrisisline.net.

We recognize that during the rollout and launch of 988, our Federal partners at the VA will face challenges in promoting widespread public awareness that the Veterans Crisis Line is reachable by text through a short code that is separate from 988. We direct Commission staff to work cooperatively with our Federal partners to promote awareness of how Service Members, Veterans, and their families can reach the Veterans Crisis Line. D. Implementation Timeframe 31.

We adopt our proposal to set a uniform nationwide implementation deadline for text-to-988 of July 16, 2022âconcurrent with 988's voice implementation deadlineâfor all covered text providers to support transmission of all covered 988 text messages. As stated above, this deadline applies only to texts the user sends to 988. It does not apply to texts to the Veterans Crisis Line using its existing short code. Guiding our decision is the need to minimize the time needed to implement text-to-988 so as to help address the growing epidemic of suicide as quickly as possible.

By setting a uniform deadline, rollout of text-to-988 will be most effective, enabling stakeholders to clearly and consistently communicate when the public can access texting services universally, while avoiding any confusion stemming from a different deadline than voice implementation. Although a phased-in approach may enable us to set a shorter deadline for some providers, this approach risks confusion not just among those âunaware of the details of staggered regulatory deadlines,â but also among those who may seek to call rather than text. Such a scenario âcould be disastrous for individuals and, in the aggregate, could erode trust in the Lifeline.â Further, we find that a July 16, 2022, deadline provides the Lifeline adequate time to prepare for additional texting volume, with Vibrant expressing confidence following its successful 2021 pilot program that âthe Lifeline has the capability to receive text-to-988 messages on the first day of 988 operation.â And as ATIS highlights, because we only require that covered text providers send text messages to the Lifeline's 10-digit number, the need for a phased approach is eliminated. 32.

We specifically set a deadline of July 16, 2022, which nearly all commenters who address timing support. Just as we concluded previously with respect to 988 implementation for voice calls, we set as early of a deadline as possible because of the numerous benefits of swift implementation in preventing suicide. As explained above, providers need not route calls to individual call centers, eliminating the need for lengthy development of new technical standards and specifications. Some providers themselves also support a July 16, 2022, deadline as providing sufficient time for implementation.

Setting a deadline for text-to-988 that matches the existing deadline for implementing calls to 988 also avoids public confusion and enhances the efficacy of marketing campaigns promoting 988. As the Mental Health Associations state, â[d]elaying an implementation deadline [beyond July 2022] will not prevent people in crisis from reaching out to 988 through text,â and such individuals will find their â[r]equest for help will go unansweredâ without action in this proceeding. 33. We reject VON's arguments that we should set a deadline of 12 months following the effective date of the order due to â[t]he need to develop and implement new routing and technical standardsâ that may pose challenges to meeting the voice deadline of July 16, 2022.

Specifically, VON compares the Lifeline's call centers to PSAPs, explaining how in the context of text-to-911, a new joint standard needed to be created in order to direct texts to the latter. However, as explained above, we do not require that providers route texts to individual call centers, but instead to the Lifeline's toll free 10-digit number. Additionally, VON cites these potential challenges only in vague terms, and claims only that they âmightâ serve as obstacles to âmeeting the voice deadline of July 16, 2022.â Moreover, as explained below, the flexible text-to-988 rules we adopt in this document do not generate significant technical obstacles, and the record's support for a July 16, 2022, deadline suggests that the issues pertinent to a texting solution specifically can be overcome in the given timeframe. For example, ATIS supports a July 16, 2022, deadline as âreasonableâ given that âit is already possible to text the existing Lifeline toll-free number,â highlighting that âtexting to the new three-digit short code (988) would create no new technical challenges.â E.

Technical Considerations 34. We adopt our proposal to allow covered text providers to use any reliable method or methods to support text routing and transmission to 988. We reiterate that covered text providers may use any reliable method or methods to support text routing and transmission to 988, and emphasize our neutrality on the technologies that covered text providers use to support text messaging to 988. We find that this approach accounts for currently-available text messaging formats and technologies and also provides the flexibility to adapt to future availability.

No commenter opposed our proposal. As ATIS explains, texting to 988 âcan and should be implemented in a timely manner[,]â Start Printed Page 405 and should âcreate no technical challenges.â 35. Network Upgrades. Based on the record, we do not expect that covered text providers will need to install significant network upgrades to implement the texting to 988 requirements adopted herein.

Though covered text providers must determine how to support texting to 988 as adopted, the rules we adopt in this document provide the flexibility to choose the most effective method for doing so. For example, covered text providers may choose to route text messages to 988 over their mobile-switched networks or use an IP-based method to deliver text messages to the Lifeline. We are encouraged that many providers have implemented voice calling to 988 a year or more before the implementation deadline, and we envision that covered text providers can also easily implement texting to 988. 36.

Equipment Upgrades. We find, based on the record, that no significant software or equipment upgrades will be necessary to implement texting to 988. We agree with ATIS, one of the organizations that set the standards for texting to 911, that â[a] focus on functionality rather than technical standards is required to meet the needs of those who communicate primarily via texting.â We are not persuaded by VON's argument that, like implementing text-to-911, industry needs to develop new routing and technical standards that may delay text-to-988's implementation. VON generically states that 911 networks and the Lifeline are âtwo distinct infrastructuresâ that will require new standards, but does not explain why these infrastructural differences merit developing new standards.

We find more convincing ATIS's assertion that changes to industry standards will âbe minimal if, as expected, no changes are required to consumer devices to support text-to-988 requirementsâ because the bulk of the record indicates that texting to 988's centralized routing solution, limited scope of text messaging service technologies, and other adopted requirements are straightforward to implement by our adoption deadline. 37. We exempt legacy devices that are incapable of sending text messages via 3-digit codes from the text-to-988 requirements, provided the software for these devices cannot be upgraded over the air to allow text-to-988. In the Text-to-911 proceeding, the Commission did not require certain legacy devices to comply with the text-to-911 requirements because âthe messaging application or interface on the mobile device will likely provide an error message indicating an invalid destination number, reducing user confusion somewhatâ that the legacy device could not support texting to 911.

No commenter discussed legacy devices nor indicated that circumstances have changed since the Commission adopted this exemption in the Text-to-911 proceeding. Accordingly, we find that the same exemption is appropriate here. 38. Network Access.

We require CMRS providers to allow access to their SMS networks by any other covered text provider for the capabilities necessary to transmit 988 text messages originating on such other covered text providers' networks, similar to the text-to-911 rules. We find this rule is necessary to implement our text to 988 requirement as we anticipate that many interconnected text providers will choose CMRS network-based solutions to implement texting to 988. No commenter opposed providing this network access. Mitel explains that, like in the texting to 911 context, routing messages to interconnected networks often requires access to an underlying wireless network and provider.

We clarify, however, that we do not intend to use these requirements to establish an open-ended obligation for CMRS providers to maintain underlying SMS network support merely for the use of other providers, nor do we require CMRS providers to reconfigure any SMS text-to-988 platforms in order to facilitate the ability of other covered text providers to access the CMRS providers' networks. Further, as with the text-to-911 rules, CMRS providers' obligation to allow access to CMRS networks âis limited to the extent that the CMRS providers offers SMS.â While we expect that adopting these rules will similarly encourage âinterconnected text providers to actively develop solutions to support [text-to-988] without reliance on CMRS providers' underlying networks,â we nonetheless encourage providers to enact solutions to carry other covered text providers' text messages to 988 over their networks. F. Other Issues 40.

Cost Recovery. We adopt our proposal to require all covered text providers to bear their own costs to implement text-to-988. We find that this approach promotes efficiency in implementation and avoids unnecessary administrative costs. In the 988 Report and Order, we observed that â[u]nlike previous numbering proceedings in which the Commission established a cost recovery mechanism,â implementation of 988 itself does not involve âshared industry costs such as central or regional numbering databases or third-party administrators.â Similarly, we conclude that implementation of a text-to-988 solution requires no shared industry costs, with costs being provider-specific and solutions unique to each.

As such, as proposed in the FNPRM we find that the requirements in section 251(e)(2) of the Act that â[t]he cost of establishing telecommunications numbering administration arrangements and number portability shall be borne by all telecommunications carriers on a competitively neutral basisâ does not apply. 41. Bounce-back Messages. We decline to require covered text providers to send an automatic bounce-back message specifically designed to address where text-to-988 service is unavailable for several reasons.

First, the record indicates that failed messages are likely to be rare. CTIA explains that network failures are ârare due to redundancies in the SMS networkâ and Vibrant indicates that to date the Lifeline's text messaging service has not experienced any downtime. Second, in the rare instance that covered text providers fail to deliver a text message to the Lifeline, current notice practices are sufficient. Individuals texting the Lifeline currently receive a bounce-back message under a variety of circumstances.

We recognize comments from CTIA which state that developing a bounce-back messaging capability âwould require substantial additional time and complexity, as well as the development of standards and requirements for implementation, and would significantly delay the July 16, 2022 implementation target.â T-Mobile further asserts that when a CMRS provider has not delivered a text message to the Lifeline due to network congestion, sending a Lifeline-specific automatic bounce-back message could be technically infeasible because â[c]arriers cannot determine if a text sent to the 10-digit Lifeline number has not been delivered due to network congestion or other factors related to nature of SMS generally.â 42. Finally, a key circumstance that prompted the Commission to require automatic bounce-back messaging for text-to-911 are not present for text-to-988. In the Text-to-911 proceeding, the Commission adopted an automatic bounce-back messaging requirement because texting was and is only available to some PSAPs, and Americans in many parts of the country could not text 911 at all. In contrast, our centralized routing approach ensures that texting to 988 will be uniformly available nationwide.

The unique geographic gaps that the bounce-back requirement addresses in the 911 context are not present here. It is possible that, as in the text-to-911 context, requiring a bounce-back message for text-to-988 could help âpersons in emergency situations being able to know immediately if a text message has been delivered to the proper authoritiesâ in the limited situations when consumers cannot send text messages to the Lifeline. However, given the urgency of improving access to lifesaving suicide prevention resources, and in light of existing protections against and in the event of a delivery failure, we decline to a bounce-back messaging requirement for text-to-988 at this time. We will monitor the operation of texting to 988 post-implementation and will not hesitate to revisit the issue of requiring a bounce-back if warranted.

43. Federal Coordination. We direct the Bureau to continue to coordinate implementation of 988 with SAMHSA, including any issues pertaining to the delivery of text messages to 988. We direct the Bureau and Commission staff to support the VA in promoting awareness of texting options for Service Members, Veterans, and their families, and to support the VA and SAMHSA in piloting, testing, and implementing any solution our Federal partners may choose to pursue to allow texting to 988 for the Veterans Crisis Line's text service.

We also encourage SAMHSA to continue to work to expand the Lifeline's texting infrastructure. We will continue to work with and support our Federal partners in their efforts to assist Americans in crisis. 44. Future Technical Corrections to Lifeline 10-Digit Number.

In our rules, we identify the current 10-digit telephone number of the Lifeline, 1-800-273-8255 (TALK). We direct the Bureau, after notice and comment, to update this reference to the correct number if the Lifeline ever changes telephone numbers. This direction applies to the text-to-988 rules we adopt in this document and to our previously-adopted 988 telephone rules. G.

Legal Authority 45. We conclude that Title III of the Act and the Twenty-First Century Communications and Video Accessibility Act (CVAA) provide us with authority for the rules we adopt in this document. No commenter opposes these conclusions. With respect to CMRS providers, we find that Title III provides us the authority to require wireless carriers to enable and support text-to-988 service.

Consistent with the U.S. Supreme Court's recognition that Title III provides the Commission a âbroad mandateâ to manage spectrum usage in the public interest, we find that significant public interest benefits will likely inure from broadly enabling access to lifesaving services through texting. Further, the rules adopted here are analogous to those the Commission adopted to facilitate text-to-911, which relied in part on the Commission's Title III authority. Therefore, with respect to CMRS providers, we conclude that Title III provides sufficient authority for the rules we adopt in this document.

46. As to interconnected text messaging service providers, the CVAA granted us authority to adopt âother regulations. . .

As are necessary to achieve reliable, interoperable communication that ensures access by individuals with disabilities to an internet protocol-enabled emergency network.â We conclude that the Lifeline constitutes an âemergency networkâ within the meaning of the CVAA. The CVAA does not define what an âemergency networkâ is, nor does it elaborate on what qualifies as âemergency services.â However, Congress, through the National Suicide Hotline Designation Act, deemed âlife-saving resourcesâ such as the Lifeline and the Veterans Crisis Line âessentialâ and recognized the need for an âeasy-to-remember, 3-digit phone numberââthat is, one readily available in an emergency situation. As CTIA argues, it is therefore reasonable to conclude that such services should be considered âemergency servicesâ and that the Lifeline and Veterans Crisis Line act as an âemergency networkâ within the meaning of the CVAA. Moreover, texting capabilities provide âeasy access to emergency services for people with disabilities,â including those with hearing and speech disabilities.

Such individuals may not be able to take advantage of 988's voice service, necessitating that an alternative means of communicating be provided. We therefore conclude that the CVAA provides authority for the rules we adopt in this document, and the record reflects agreement with our analysis. Because we find that Title III and the CVAA provide sufficient authority for the rules we adopt in this document, we find it unnecessary to address other possible sources of authority to adopt these rules. H.

Benefits and Costs of Text-to-988 47. Consistent with our proposal in the FNPRM, we find that benefits of requiring service providers to support text-to-988 far exceed the costs of implementation. The loss of victims' lives to suicide cannot be adequately captured by any pecuniary measure. The principal benefit of text-to-988 is that it will reduce suicide risk by providing an additional means of reaching help for the most vulnerable.

Text-to-988 will reduce the risk of suicide mortality, primarily among those who would either send a text to 988 or forgo a lifesaving intervention altogether. Three vulnerable communities, in particular, face this stark choice. Youth, who rely heavily on text messages for their general communications needs. The deaf, deafblind, hard of hearing, and speech disabled.

And those who are reluctant to dial 988 because they feel unsafe, ashamed or embarrassed, including many LGBTQ+ youth and victims of domestic abuse. As outlined Start Printed Page 407 above, the ability to text to the short and easy-to-remember 988 code will make the lifesaving interventions of the Lifeline crisis centers even more accessible than dialing alone. As no commenter in the record disputes, we find that the benefits of implementing text-to-988 will quickly exceed costs, and dwarf them over time. 48.

In the FNPRM, we estimated the cost of implementing text to 988 would be nearly $27 million over five years. We based our estimate on find more info Intrado's existing estimates of the costs of upgrading 911 call centers to receive text messages. Although one commenter asserts that the costs of implementation are likely to be âsubstantially lowerâ than our estimate, no commenters provided any individual estimates or disputed our underlying approach or our estimate of the combined total cost of nearly $27 million with an alternate figure. We agree that implementation costs may be lower than we projected.

These â[e]mergency department visits for mental health and substance use disorders cost an average of $520 across 10.7 million visits in 2017, for a total cost nationwide of nearly $5.6 billion.â Any reduction in these visits and resulting cost savings are benefits of implementing text-to-988. In addition, the Center for Law and Social Policy (CLASP) points to an evaluation of Nevada's TextToday pilot program, one of the country's first crisis response lines that accepted text messages. The evaluation found an increase in help-seeking by youth and a preference for texting. Groups that would be especially likely to benefit from text-to-988 are members of the LGBTQ+ community, and deaf, deafblind, hard of hearing, and speech-disabled adults.

Between 2015 and 2019, we estimate there were more than 39,000 suicides among youth 10-19, LGBTQ+ adults, and deaf, deafblind, hard of hearing, and speech-disabled adults. If text-to-988 reduces the annual risk of suicide mortality among these groups and others by even a very small amount, the benefits would easily outweigh the costs of implementing text-to-988. II. Final Regulatory Flexibility Analysis 1.

As required by the Regulatory Flexibility Act of 1980, as amended (RFA), an Initial Regulatory Flexibility Analysis (IRFA) was incorporated into the FNPRM, released April 2021. The Commission sought written public comments on the proposals in the FNPRM, including comment on the IRFA. No comments were filed addressing the IRFA. Because the Commission amends its rules in the Second Report and Order, the Commission has included this Final Regulatory Flexibility Analysis (FRFA).

This present FRFA conforms to the RFA. A. Need for, and Objectives of, the Rules 2. In the Second Report and Order, the Commission adopts rules requiring CMRS providers and providers of interconnected text messaging services that enable consumers to send text messages to, and receive text messages from, all or substantially all text-capable U.S.

Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones (covered text providers) to enable delivery of text messages to 988. The Commission further requires that covered text providers route 988 text messages to the National Suicide Prevention Lifeline's (Lifeline) 10-digit number, currently 1-800-273-8255 (TALK). The Commission believes these rules will expand the availability of mental health and crisis counseling resources to Americans who suffer from depressive or suicidal thoughts, by allowing individuals in crisis to reach the Lifeline by texting 988. B.

Summary of Significant Issues Raised by Public Comments in Response to the IRFA 3. There were no comments filed that specifically addressed the proposed rules and policies presented in the IRFA. C. Response to Comments by the Chief Counsel for Advocacy of the Small Business Administration 4.

Pursuant to the Small Business Jobs Act of 2010, which amended the RFA, the Commission is required to respond to any comments filed by the Chief Counsel for Advocacy of the Small Business Administration (SBA), and to provide a detailed statement of any change made to the proposed rules as a result of those comments. 5. The Chief Counsel did not file any comments in response to the proposed rules in this proceeding. D.

Description and Estimate of the Number of Small Entities to Which the Rules Will Apply 6. The RFA directs agencies to provide a description of, and where feasible, an estimate of the number of small entities that may be affected by the final rules adopted pursuant to the Second Report and Order. The RFA generally defines the term âsmall entityâ as having the same meaning as the terms âsmall business,â âsmall organization,â and âsmall governmental jurisdiction.â In addition, the term âsmall businessâ has the same meaning as the term âsmall-business concernâ under the Small Business Act. A âsmall-business concernâ is one which.

(1) Is independently owned and operated. (2) is not dominant in its field of operation. And (3) satisfies any additional criteria established by the SBA. 7.

Small Businesses, Small Organizations, Small Governmental Jurisdictions. Our actions, over time, may affect small entities that are not easily categorized at present. We therefore describe here, at the outset, three broad groups of small entities that could be directly affected herein. First, while there are industry specific size standards for small businesses that are used in the regulatory flexibility analysis, according to data from the SBA's Office of Advocacy, in general a small business is an independent business having fewer than 500 employees.

These types of small businesses represent 99.9% of all businesses in the United States, which translates to 30.7 million businesses. 8. Next, the type of small entity described as a âsmall organizationâ is generally âany not-for-profit enterprise which is independently owned and operated and is not dominant in its field.â The Internal Revenue Service (IRS) uses a revenue benchmark of $50,000 or less to delineate its annual electronic filing requirements for small exempt organizations. Nationwide, for tax year 2018, there were approximately 571,709 small exempt organizations in the U.S.

Reporting revenues of $50,000 or less according to the registration and tax data for exempt organizations available from the IRS. 9. Finally, the small entity described as a âsmall governmental jurisdictionâ is defined generally as âgovernments of cities, counties, towns, townships, villages, school districts, or special districts, with a population of less than fifty thousand.â U.S. Census Bureau data from the 2017 Census of Governments indicate that there were 90,075 local governmental jurisdictions consisting of general purpose Start Printed Page 408 governments and special purpose governments in the United States.

Of this number there were 36,931 general purpose governments (county, municipal and town or township) with populations of less than 50,000 and 12,040 special purpose governmentsâindependent school districts with enrollment populations of less than 5ll governmental jurisdictions. 10. Wired Telecommunications Carriers. The U.S.

Census Bureau defines this industry as âestablishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired communications networks. Transmission facilities may be based on a single technology or a combination of technologies. Establishments in this industry use the wired telecommunications network facilities that they operate to provide a variety of services, such as wired telephony services, including [voice over internet protocol] VoIP services, wired (cable) audio and video programming distribution, and wired broadband internet services. By exception, establishments providing satellite television distribution services using facilities and infrastructure that they operate are included in this industry.â The SBA has developed a small business size standard for Wired Telecommunications Carriers, which consists of all such companies having 1,500 or fewer employees.

U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated that year. Of this total, 3,083 operated with fewer than 1,000 employees. Thus, under this size standard, the majority of firms in this industry can be considered small.

11. Local Exchange Carriers (LECs). Neither the Commission nor the SBA has developed a size standard for small businesses specifically applicable to local exchange services. The closest applicable North American Industry Classification System (NAICS) Code category is Wired Telecommunications Carriers.

Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated for the entire year. Of that total, 3,083 operated with fewer than 1,000 employees.

Thus under this category and the associated size standard, the Commission estimates that the majority of local exchange carriers are small entities. 12. Incumbent Local Exchange Carriers (Incumbent LECs). Neither the Commission nor the SBA has developed a small business size standard specifically for incumbent local exchange services.

The closest applicable NAICS Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated the entire year.

Of this total, 3,083 operated with fewer than 1,000 employees. Consequently, the Commission estimates that most providers of incumbent local exchange service are small businesses that may be affected by our actions. According to Commission data, one thousand three hundred and seven (1,307) Incumbent Local Exchange Carriers reported that they were incumbent local exchange service providers. Of this total, an estimated 1,006 have 1,500 or fewer employees.

Thus, using the SBA's size standard the majority of incumbent LECs can be considered small entities. 13. Competitive Local Exchange Carriers (Competitive LECs). Competitive Access Providers (CAPs), Shared-Tenant Service Providers, and Other Local Service Providers.

Neither the Commission nor the SBA has developed a small business size standard specifically for these service providers. The appropriate NAICS Code category is Wired Telecommunications Carriers and under that size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated during that year.

Of that number, 3,083 operated with fewer than 1,000 employees. Based on these data, the Commission concludes that the majority of Competitive LECS, CAPs, Shared-Tenant Service Providers, and Other Local Service Providers, are small entities. According to Commission data, 1,442 carriers reported that they were engaged in the provision of either competitive local exchange services or competitive access provider services. Of these 1,442 carriers, an estimated 1,256 have 1,500 or fewer employees.

In addition, 17 carriers have reported that they are Shared-Tenant Service Providers, and all 17 are estimated to have 1,500 or fewer employees. Also, 72 carriers have reported that they are Other Local Service Providers. Of this total, 70 have 1,500 or fewer employees. Consequently, based on internally researched FCC data, the Commission estimates that most providers of competitive local exchange service, competitive access providers, Shared-Tenant Service Providers, and Other Local Service Providers are small entities.

The applicable size standard under SBA rules is that such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated for the entire year. Of that number, 3,083 operated with fewer than 1,000 employees.

According to internally developed Commission data, 359 companies reported that their primary telecommunications service activity was the provision of interexchange services. Of this total, an estimated 317 have 1,500 or fewer employees. Consequently, the Commission estimates that the majority of interexchange service providers are small entities. 15.

Local Resellers. The SBA has not developed a small business size standard specifically for Local Resellers. The SBA category of Telecommunications Resellers is the closest NAICS code category for local resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households.

Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. Mobile virtual network operators (MVNOs) are included in this industry. Under the SBA's size standard, such a business is small if it has 1,500 or fewer employees.

U.S. Census Bureau data from 2012 show that 1,341 firms provided resale services during that year. Of that number, all operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities.

According to Commission data, 213 carriers have reported that they are engaged in the provision of local resale services. Of these, an estimated 211 have 1,500 or fewer employees and two have more than 1,500 employees. Consequently, the Commission estimates that the majority of local resellers are small entities. 16.

Toll Resellers. The Commission has not developed a definition for Toll Resellers. The closest NAICS Code Category is Telecommunications Start Printed Page 409 Resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households.

Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. MVNOs are included in this industry. The SBA has developed a small business size standard for the category of Telecommunications Resellers.

Under that size standard, such a business is small if it has 1,500 or fewer employees. 2012 U.S. Census Bureau data show that 1,341 firms provided resale services during that year. Of that number, 1,341 operated with fewer than 1,000 employees.

Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities. According to Commission data, 881 carriers have reported that they are engaged in the provision of toll resale services. Of this total, an estimated 857 have 1,500 or fewer employees. Consequently, the Commission estimates that the majority of toll resellers are small entities.

17. Other Toll Carriers. Neither the Commission nor the SBA has developed a definition for small businesses specifically applicable to Other Toll Carriers. This category includes toll carriers that do not fall within the categories of interexchange carriers, operator service providers, prepaid calling card providers, satellite service carriers, or toll resellers.

The closest applicable size standard under SBA rules is for Wired Telecommunications Carriers. The applicable SBA size standard consists of all such companies having 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicates that 3,117 firms operated during that year.

Of that number, 3,083 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of Other Toll Carriers can be considered small. According to internally developed Commission data, 284 companies reported that their primary telecommunications service activity was the provision of other toll carriage. Of these, an estimated 279 have 1,500 or fewer employees.

Consequently, the Commission estimates that most Other Toll Carriers are small entities. 18. Prepaid Calling Card Providers. Neither the Commission nor the SBA has developed a small business definition specifically for prepaid calling card providers.

The most appropriate NAICS code-based category for defining prepaid calling card providers is Telecommunications Resellers. This industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure.

MVNOs are included in this industry. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that 1,341 firms provided resale services during that year.

Of that number, 1,341 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these prepaid calling card providers can be considered small entities. According to the Commission's Form 499 Filer Database, 86 active companies reported that they were engaged in the provision of prepaid calling cards. The Commission does not have data regarding how many of these companies have 1,500 or fewer employees, however, the Commission estimates that the majority of the 86 active prepaid calling card providers that may be affected by these rules are likely small entities.

19. Wireless Telecommunications Carriers (except Satellite). This industry comprises establishments engaged in operating and maintaining switching and transmission facilities to provide communications via the airwaves. Establishments in this industry have spectrum licenses and provide services using that spectrum, such as cellular services, paging services, wireless internet access, and wireless video services.

The appropriate size standard under SBA rules is that such a business is small if it has 1,500 or fewer employees. For this industry, U.S. Census Bureau data for 2012 show that there were 967 firms that operated for the entire year. Of this total, 955 firms employed fewer than 1,000 employees and 12 firms employed of 1000 employees or more.

Similarly, according to internally developed Commission data, 413 carriers reported that they were engaged in the provision of wireless telephony, including cellular service, Personal Communications Service (PCS), and Specialized Mobile Radio (SMR) Telephony services. Of this total, an estimated 261 have 1,500 or fewer employees, and 152 have more than 1,500 employees. Thus, using available data, we estimate that the majority of wireless firms can be considered small. 21.

Cable and Other Subscription Programming. The U.S. Census Bureau defines this industry as establishments primarily engaged in operating studios and facilities for the broadcasting of programs on a subscription or fee basis. The broadcast programming is typically narrowcast in nature ( e.g., limited format, such as news, sports, education, or youth-oriented).

These establishments produce programming in their own facilities or acquire programming from external sources. The programming material is usually delivered to a third party, such as cable systems or direct-to-home satellite systems, for transmission to viewers. The SBA size standard for this industry establishes as small any company in this category with annual receipts less than $41.5 million. Based on U.S.

Census Bureau data for 2012, 367 firms operated for the entire year. Of that number, 319 firms operated with annual receipts of less than $25 million a year and 48 firms operated with annual receipts of $25 million or more. Based on this data, the Commission estimates that a majority of firms in this industry are small. 22.

Cable Companies and Systems (Rate Regulation). The Commission has also developed its own small business size standards, for the purpose of cable rate regulation. Under the Commission's rules, a âsmall cable companyâ is one serving 400,000 or fewer subscribers nationwide. Industry data indicate that there are 4,600 active cable systems in the United States.

Of this total, all but five cable operators nationwide are small under the 400,000-subscriber size standard. In addition, under the Commission's rate regulation rules, a âsmall systemâ is a cable system serving 15,000 or fewer subscribers. Commission records show 4,600 cable systems nationwide. Of this total, 3,900 cable systems have fewer than 15,000 subscribers, and 700 systems have Start Printed Page 410 15,000 or more subscribers, based on the same records.

Thus, under this standard as well, we estimate that most cable systems are small entities. 23. Cable System Operators (Telecom Act Standard). The Communications Act of 1934, as amended, also contains a size standard for small cable system operators, which is âa cable operator that, directly or through an affiliate, serves in the aggregate fewer than one percent of all subscribers in the United States and is not affiliated with any entity or entities whose gross annual revenues in the aggregate exceed $250,000,000.â As of 2019, there were approximately 48,646,056 basic cable video subscribers in the United States.

Accordingly, an operator serving fewer than 486,460 subscribers shall be deemed a small operator if its annual revenues, when combined with the total annual revenues of all its affiliates, do not exceed $250 million in the aggregate. Based on available data, we find that all but five cable operators are small entities under this size standard. We note that the Commission neither requests nor collects information on whether cable system operators are affiliated with entities whose gross annual revenues exceed $250 million. Therefore, we are unable at this time to estimate with greater precision the number of cable system operators that would qualify as small cable operators under the definition in the Communications Act.

24. All Other Telecommunications. The âAll Other Telecommunicationsâ category is comprised of establishments primarily engaged in providing specialized telecommunications services, such as satellite tracking, communications telemetry, and radar station operation. This industry also includes establishments primarily engaged in providing satellite terminal stations and associated facilities connected with one or more terrestrial systems and capable of transmitting telecommunications to, and receiving telecommunications from, satellite systems.

Establishments providing internet services or VoIP services via client-supplied telecommunications connections are also included in this industry. The SBA has developed a small business size standard for âAll Other Telecommunicationsâ, which consists of all such firms with annual receipts of $35 million or less. For this category, U.S. Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year.

Of those firms, a total of 1,400 had annual receipts less than $25 million and 15 firms had annual receipts of $25 million to $49,999,999. Thus, the Commission estimates that the majority of âAll Other Telecommunicationsâ firms potentially affected by our action can be considered small. 25. Radio and Television Broadcasting and Wireless Communications Equipment Manufacturing.

This industry comprises establishments primarily engaged in manufacturing radio and television broadcast and wireless communications equipment. Examples of products made by these establishments are. Transmitting and receiving antennas, cable television equipment, Global Positioning System (GPS) equipment, pagers, cellular phones, mobile communications equipment, and radio and television studio and broadcasting equipment. The SBA has established a small business size standard for this industry of 1,250 employees or less.

U.S. Census Bureau data for 2012 show that 841 establishments operated in this industry in that year. Of that number, 828 establishments operated with fewer than 1,000 employees, 7 establishments operated with between 1,000 and 2,499 employees and 6 establishments operated with 2,500 or more employees. Based on this data, we conclude that a majority of manufacturers in this industry are small.

26. Semiconductor and Related Device Manufacturing. This industry comprises establishments primarily engaged in manufacturing semiconductors and related solid state devices. Examples of products made by these establishments are integrated circuits, memory chips, microprocessors, diodes, transistors, solar cells and other optoelectronic devices.

The SBA has developed a small business size standard for Semiconductor and Related Device Manufacturing, which consists of all such companies having 1,250 or fewer employees. U.S. Census Bureau data for 2012 show that there were 862 establishments that operated that year. Of this total, 843 operated with fewer than 1,000 employees.

Thus, under this size standard, the majority of firms in this industry can be considered small. 27. Software Publishers. This industry comprises establishments primarily engaged in computer software publishing or publishing and reproduction.

Establishments in this industry carry out operations necessary for producing and distributing computer software, such as designing, providing documentation, assisting in installation, and providing support services to software purchasers. These establishments may design, develop, and publish, or publish only. The SBA has established a size standard for this industry of annual receipts of $41.5 million or less per year. U.S.

Census data for 2012 indicates that 5,079 firms operated for the entire year. Of that number 4,691 firms had annual receipts of less than $25 million and 166 firms had annual receipts of $25,000,000 to $49,999,999. Based on this data, we conclude that a majority of firms in this industry are small. 28.

Internet Service Providers (Broadband). Broadband internet service providers include wired ( e.g., cable, digital subscriber line (DSL)) and VoIP service providers using their own operated wired telecommunications infrastructure fall in the category of Wired Telecommunication Carriers. Wired Telecommunications Carriers are comprised of establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired telecommunications networks. Transmission facilities may be based on a single technology or a combination of technologies.

The SBA size standard for this category classifies a business as small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated that year. Of this total, 3,083 operated with fewer than 1,000 employees.

Consequently, under this size standard the majority of firms in this industry can be considered small. 29. Internet Service Providers (Non-Broadband). Internet access service providers such as dial-up internet service providers (ISPs), VoIP service providers using client-supplied telecommunications connections and internet service providers using client-supplied telecommunications connections ( e.g., dial-up ISPs) fall in the category of All Other Telecommunications.

The SBA has developed a small business size standard for All Other Telecommunications which consists of all such firms with gross annual receipts of $35 million or less. For this category, U.S. Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year. Of these firms, a total of 1,400 had gross annual receipts of less than $25 million.

Consequently, under this size standard a majority of firms in this industry can be considered small. 30. All Other Information Services. The U.S.

Census Bureau has determined that this category âcomprises establishments primarily engaged in providing other information services (except news syndicates, libraries, archives, internet publishing and Start Printed Page 411 broadcasting, and Web search portals).â The SBA has developed a small business size standard for this category, which consists of all such firms with annual receipts of $30 million or less. U.S. Census Bureau data for 2012 show that there were 512 firms that operated for the entire year. Of those firms, a total of 498 had annual receipts less than $25 million and 7 firms had annual receipts of $25 million to $49,999,999.

It concludes that text-to-988 functionality will greatly improve consumer access to the Lifeline, particularly for at-risk populations and thereby save lives. The final rules adopted in the Second Report and Order require CMRS providers and interconnected text messaging service providers to route texts sent to 988 to the 10-digit Lifeline number, presently 1-800-273-8255 (TALK). The Second Report and Order (1) establishes a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support. (2) directs the Wireline Competition Bureau (Bureau) to identify text formats within the scope of that definition that the Lifeline can receive and thus covered text providers must support by routing to the 10-digit Lifeline number.

And (3) requires CMRS providers that offer SMS to allow access by any other covered text provider to the capabilities necessary for transmission of 988 text messages originating on such other covered text providers' application services. F. Steps Taken To Minimize the Significant Economic Impact on Small Entities, and Significant Alternatives Considered 32. The RFA requires an agency to describe any significant, specifically small business, alternatives that it has considered in reaching its approach, which may include the following four alternatives (among others).

Â(1) the establishment of differing compliance or reporting requirements or timetables that take into account the resources available to small entities. (2) the clarification, consolidation, or simplification of compliance and reporting requirements under the rules for such small entities. (3) the use of performance rather than design standards. And (4) an exemption from coverage of the rule, or any part thereof, for such small entities.â 33.

In the Second Report and Order, the Commission adopts a uniform implementation deadline for all covered text providers to route covered 988 text messages to 988 to the Lifeline's 10-digit number by July 16, 2022. The Commission believes that applying the same rules equally to all entities in this context is necessary to alleviate potential consumer confusion from adopting different rules, at different times, for different covered text providers. However, the Commission does not believe that the actions in the Second Report and Order will overly burden small carriers or providers. Further, the Commission believes that by its actions, all entities, including small carriers or providers, will benefit from reduced costs.

For example, the Commission believes that adopting our proposal to require all covered text providers to bear their own costs to implement text-to-988 will avoid any unnecessary administrative costs. Further, the Commission provides covered text provider flexibility in how they support texting to 988, allowing them to choose the most effective method for doing so. G. Report to Congress 34.

The Commission will send a copy of the Second Report and Order, including this FRFA, in a report to be sent to Congress pursuant to the Congressional Review Act. In addition, the Commission will send a copy of the Second Report and Order, including this FRFA, to the Chief Counsel for Advocacy of the SBA. A copy of the Second Report and Order and FRFA (or summaries thereof) will also be published in the Federal Register. III.

Procedural Matters 35. Paperwork Reduction Act of 1995 Analysis. This document does not contain proposed information collection(s) subject to the Paperwork Reduction Act of 1995 (PRA), Public Law 104-13. In addition, therefore, it does not contain any new or modified information collection burden for small business concerns with fewer than 25 employees, pursuant to the Small Business Paperwork Relief Act of 2002, Public Law 107-198, see 44 U.S.C.

3506(c)(4). 36. Final Regulatory Flexibility Analysis. As required by the Regulatory Flexibility Act of 1980,103 the Commission has prepared a Final Regulatory Flexibility Analysis (FRFA) of the possible significant economic impact on small entities of the policies and rules, as proposed, addressed in the Second Report and Order.

The FRFA is set forth in Appendix B of the Second Report and Order. The Commission will send a copy of the Second Report and Order, including the FRFA, to the Chief Counsel for Advocacy of the Small Business Administration (SBA). 37. Congressional Review Act.

The Commission has determined, and the Administrator of the Office of Information and Regulatory Affairs, Office of Management and Budget, concurs that this rule is non-major under the Congressional Review Act, 5 U.S.C. 804(2). The Commission will send a copy of the Second Report and Order to Congress and the Government Accountability Office pursuant to 5 U.S.C. 801(a)(1)(A).

38. People With Disabilities. To request materials in accessible formats for people with disabilities (braille, large print, electronic files, audio format), send an email to fcc504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at (202) 418-0530 (voice), 202-418-0432 (tty).

39. Contact Person. For further information about this rulemaking proceeding, please contact Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388 or michelle.sclater@fcc.gov. IV.

Ordering Clauses 40. Accordingly, it is ordered , pursuant to sections 201, 251(e)(4), 301, 303, 307, 309, 316, and 615c of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251(e)(4), 301, 303, 307, 309, 316, 615c, that the Second Report and Order in WC Docket No. 18-336 is adopted.

41. It is further ordered that, pursuant to Â§Â§â1.4(b)(1) and 1.103(a) of the Commission's rules, 47 CFR 1.4(b)(1), 1.103(a), the Report and Order shall be effective 30 days after publication in the Federal Register. 42. It is further ordered that part 52 of the Commission's rules is amended as set forth in Appendix A of the Second Report and Order.

It is further ordered that the Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, shall send a copy of the Second Report and Order, including the Final Regulatory Flexibility Analysis (FRFA), to the Chief Counsel for Advocacy of the Small Business Administration. Start List of Subjects Start Printed Page 412 Communications common carriersTelecommunicationsTelephone End List of Subjects (47 U.S.C. 201, 251, 301, 303, 307, 309, 316) Start Signature Federal Communications Commission. Katura Jackson, Federal Register Liaison Officer.

End Signature Final Rules For the reasons stated in the preamble, the Federal Communications Commission amends 47 CFR part 52 as follows. Start Part End Part Start Amendment Part1. The authority citation for part 52 continues to read as follows. End Amendment Part Start Authority 47 U.S.C.

151, 152, 153, 154, 155, 201-205, 207-209, 218, 225-227, 251-252, 271, 303, 332, unless otherwise noted. End Authority Start Amendment Part2. Add Â§â52.201 to read as follows. End Amendment Part Texting to the National Suicide Prevention and Mental Health Crisis Hotline.

(a) Support for 988 text message service. Beginning July 16, 2022, all covered text providers must route a covered 988 text message to the current toll free access number for the National Suicide Prevention Lifeline, presently 1-800-273-8255 (TALK). (b) Access to SMS networks for 988 text messages. To the extent that Commercial Mobile Radio Services (CMRS) providers offer Short Message Service (SMS), they shall allow access by any other covered text provider to the capabilities necessary for transmission of 988 text messages originating on such other covered text providers' application services.

(c) Definitions. For purposes of this section. 988 text message. (i) Means a message consisting of text, images, sounds, or other information that is transmitted to or from a device that is identified as the receiving or transmitting device by means of a 10-digit telephone number, N11 service code, or 988.

(ii) Includes and is not limited to a SMS message and a multimedia message service (MMS) message. And (iii) Does not includeâ (A) A real-time, two-way voice or video communication. Or (B) A message sent over an IP-enabled messaging service to another user of the same messaging service, except a message described in paragraph (b) of this section. Covered 988 text message means a 988 text message in SMS format and any other format that the Wireline Competition Bureau has determined must be supported by covered text providers.

Covered text provider includes all CMRS providers as well as all providers of interconnected text messaging services that enable consumers to send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones. Multimedia message service ( MMS ) shall have the same definition as the term in Â§â64.1600(k) of this chapter. Short message service ( SMS ) shall have the same definition as the term in Â§â64.1600(m) of this chapter.

End Supplemental Information [FR Doc. 2021-27878 Filed 1-4-22. 8:45 am]BILLING CODE 6712-01-P.

Farmers and people in rural areas are more comfortable talking about stress buy amoxil with free samples and mental health challenges with others, and stigma around seeking help or treatment has decreased in rural and farm communities but is still a factor, according to a new research poll from the American Farm Bureau Federation. AFBF conducted the survey of rural adults and farmers/farmworkers to measure changes and trends in stigma, personal experiences with mental health, awareness of information about mental health resources and comfort in talking about mental health with others. The poll results were compared with previous buy amoxil with free samples surveys AFBF conducted in 2019 and 2020 focusing on farmer mental health, and the impacts of the buy antibiotics amoxil on farmer mental health, respectively. ÂFarm Bureau has been encouraging conversations to help reduce stigma around farmer stress and mental health through our Farm State of Mind campaign,â said AFBF President Zippy Duvall. ÂThis poll shows that we are making a difference, but we all still have work to do.

Itâs up to each of us to keep looking out for our family, friends and neighbors and let them know theyâre not alone when they feel the increasing stress that comes with the daily business of farming and ranching.â Morning Consult conducted the poll on behalf of AFBF in December 2021 among a national sample of 2,000 buy amoxil with free samples rural adults. Key findings include. Stigma around seeking help or treatment for mental health has decreased but is still a factor, particularly in agriculture. Over the past year, there has been a decrease buy amoxil with free samples in rural adults saying their friends/acquaintances (-4%) and people in their local community (-9%) attach stigma to seeking help or treatment for mental health. But a majority of rural adults (59%) say there is at least some stigma around stress and mental health in the agriculture community, including 63% of farmers/farm workers.

Farmers/farm workers are more comfortable talking to friends, family and their doctors buy amoxil with free samples about stress and mental health than they were in 2019. Four in five rural adults (83%) and 92% of farmers/farm workers say they would be comfortable talking about solutions with a friend or family member dealing with stress or a mental health condition, and the percentage of farmers/farm workers who say they would be comfortable talking to friends and family members has increased 22% since April 2019. A majority of rural adults (52%) and farmers/farm workers (61%) are experiencing more stress and mental health challenges compared to a year ago, and they are seeking care because of increased stress. Younger rural adults are more likely than older rural adults to say they are experiencing more stress and mental health challenges compared to a year ago, and they are more likely than older rural buy amoxil with free samples adults to say they have personally sought care from a mental health professional. A slide deck with additional detail on the full survey results is available here.

AFBF will be featuring two events focused on farmer mental health at the 103rd AFBF Convention in Atlanta, Georgia. A panel discussion with Farm Bureau representatives on Sunday, buy amoxil with free samples Jan. 9, at 10:45 a.m. EST, and a QPR mental health training workshop conducted by AgriSafe that offers farmers and farm families skills to recognize and respond to mental health crises using the Question, Persuade buy amoxil with free samples and Refer approach, on Monday, Jan. 10, at 2:00 p.m.

EST. If you or someone you know is struggling emotionally or has concerns about their mental health, visit the buy amoxil with free samples Farm State of Mind website at farmstateofmind.org for information on crisis hotlines, treatment locators, tips for helping someone in emotional pain, ways to start a conversation and resources for managing stress, anxiety or depression. Contact. Mike TomkoDirector, Communications(202) 406-3642miket@fb.org Ray AtkinsonDirector, Communications(202) 406-3717raya@fb.org Return to NewsroomStart Preamble Federal Communications Commission. Final rule buy amoxil with free samples.

In this document, the Federal Communications Commission (Commission or FCC) requires all covered text providers to support text messaging to 988, the 3-digit dialing code to reach the National Suicide Prevention Lifeline, by July 16, 2022. Given the popularity of text messaging, particularly among at-risk populations, it is essential for Americans to be able to text the Lifeline with the same short, buy amoxil with free samples easy-to-remember code by which they will be able to call the Lifeline. This rule is effective February 4, 2022. Start Further Info Start Printed Page 399 Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388, Michelle.Sclater@fcc.gov. End Further Info End Preamble Start Supplemental Information This is a summary of buy amoxil with free samples the Commission's Second Report and Order (SRO) in WC Docket No.

18-336, adopted on November 18, 2021and released on November 19, 2021. The document is available for download at https://docs.fcc.gov/âpublic/âattachments/âFCC-21-119A1.pdf. To request materials in accessible formats for people with disabilities (Braille, large print, electronic files, audio format), send an email to FCC504@fcc.gov buy amoxil with free samples or call the Consumer &. Governmental Affairs Bureau at 202-418-0530 (voice), 202-418-0432 (TTY). Synopsis I.

Second Report and Order buy amoxil with free samples A. Text-to-988 Will Save Lives 1. We conclude that requiring buy amoxil with free samples covered text providers to support text-to-988 will save lives. No commenter in the record opposes adoption of a text-to-988 requirement. As Americans become more reliant on texting to communicate, the need to access mental health assistance and resources by text is essential.

Text messaging to the Lifeline will facilitate access to critical buy amoxil with free samples mental health resources for all, and particularly for at-risk populations who tend to prefer communicating through text rather than phone calls. 2. The record reflects overwhelming support for the conclusion that text-to-988 functionality will greatly improve consumer access to the Lifeline. Over 14 National Alliance on Mental Illness (NAMI) offices across the United buy amoxil with free samples States filed in support of text messaging to 988. Substance Abuse and Mental Health Services Administration (SAMHSA), the Government agency responsible for overseeing the Lifeline, states that texting capability would improve equitable access to the Lifeline, especially for at-risk communities.

And Vibrant, the administrator buy amoxil with free samples of the Lifeline, also notes that âtext-to-988 capability would improve consumer accessibility to the Lifeline and save lives.â Mental Health America suggests that â[i]f 988 is implemented without support for text messaging, individuals in need of mental health crisis services, particularly youth and adolescents, will remain unanswered.â A bipartisan group of U.S. Representatives from Colorado express their support, stating that â[b]y allowing a text-to-988 option in addition to voice call, the Commission can lower the bar to entry and improve access to crisis counseling and mental health services.â Text-to-988 will provide greater access to anyone who is not comfortable calling the Lifeline or cannot make a phone call. For instance, individuals who are in abusive or controlling situations may feel safer texting than making a verbal call when in a crisis. Similarly, for individuals who are helping someone who is experiencing symptoms such as paranoia or delusions and appears threatening, texting offers greater safety buy amoxil with free samples when reaching out for crisis assistance. 3.

The record also demonstrates that requiring covered text providers to support text-to-988 functionality will provide significant benefits to at-risk populations, particularly to young Americans who are disproportionately at risk for mental health crises. Research shows that serious psychological distress, major depression, and suicidal thoughts and attempts among adolescents buy amoxil with free samples and young adults have increased significantly in recent years. SAMHSA explains that individuals who send texts or online chats to the Lifeline both skew younger and are more likely to experience current suicidal ideation relative to the categories of individuals who typically access the Lifeline via phone. Nearly 95% buy amoxil with free samples of teens have access to smart phones and report that texting is the primary way by which they connect. According to Mental Health America, â[m]ultiple sources of data demonstrate youth prefer communicating by text rather than calls,â including a study finding that young people âwere more likely to forgo psychological support than talk in person or over the phone.â Nevada, which conducted one of the country's first text messaging for crisis response pilot programs, TextToday, found an increase in help-seeking behaviors by youth as a result of the program and a preference for texting among the youth age cohort.

Some members of at-risk populations may prefer or find it easier to access the Lifeline via text as compared to the online chat portal, which requires people to have internet access, find the website, and locate the chat portal. A survey addressing how teens are coping and connecting during buy antibiotics reported that buy amoxil with free samples 65% of teens used texting to communicate with friends and family more than usual in response to the amoxil. 4. In addition to young Americans, text-to-988 will help other American communities that are disproportionately impacted by suicide, including Veterans, LGBTQ+ individuals, racial and ethnic minorities, and rural Americans. Death by buy amoxil with free samples suicide amongst Veterans has steadily increased over the past several years.

Furthermore, the suicide rate has risen faster among Veterans than it has for non-Veteran adults. LGBTQ+ youth are nearly five times as likely to have attempted suicide compared to heterosexual youth, and the suicide rate for Black children ages 5-12 is about two times higher compared to white children. The record indicates that these at-risk communities may use text services at higher rates buy amoxil with free samples than other communities. For example, NAMI reports that people of color text at a higher rate than white individuals, and lower-income households send twice as many texts than households with higher incomes. Mental Health America notes that data they collected demonstrate that individuals âwho identify as Black or African American are more likely to report that they would like to buy amoxil with free samples receive a phone number they can immediately call or text for helpâ than members of any other race or ethnicity.

Individuals from communities, religious groups, or ethnic backgrounds that have been found to have lower professional help-seeking behaviors or whose communities are less typically accepting of mental health treatment will also benefit from the added privacy of seeking crisis support via text. 5. Text messaging has also become a crucial form of communication for people who are deaf, hard of hearing, or have other disabilities that impact communication buy amoxil with free samples. Studies find an increased risk of suicide among deaf and hard of hearing people when compared to those without hearing loss. These individuals have increasingly adopted widely available text messaging platforms in lieu of specialized legacy devices, such as text telephones (TTY), because of the ease of access, wide availability, and practicability of modern text-capable devices.

Some individuals with disabilities find buy amoxil with free samples it more effective to access mental health support through text messaging over other means of communications. Vibrant notes that for individuals in the disability community, the ability to text crisis services directly, without need for an intermediary interpreter or service, provides âsubstantial benefit.â SAMHSA highlights the convenience texting would provide to people with autism spectrum disorder (ASD), who are at an increased risk for suicide, yet may have âdifficulties with back and forth conversations, and may therefore prefer to text rather than call the Lifeline.â Access to communications capabilities for individuals with disabilities is a longstanding Commission priority and statutory obligation. Our requirement to support Start Printed Page 400 text-to-988 broadens access to 988 and helps ensure individuals with disabilities buy amoxil with free samples that impact communication can more easily reach lifesaving resources. 6. The Commission's designation of 988 as the 3-digit telephone number for the Lifeline reflected its expectation that a simple, easy-to-remember, 3-digit dialing code for suicide prevention and mental health crisis counseling would âhelp increase the effectiveness of suicide prevention efforts, ease access to crisis services, reduce the stigma surrounding suicide and mental health conditions, and ultimately save lives.â We conclude that providing text access at the same short code number will generate synergies that enhance the value of efforts to promote 988.

We are buy amoxil with free samples also mindful that the promotion and availability of the 988 short code for telephone calls to the Lifeline crisis hotline, and by extension the Veterans Crisis Line, could create confusion as to whether that number is available for, and capable of, receiving text messages. We find that requiring providers to implement text-to-988 will also help to avoid confusion or putting lives at risk. B. Designating a Wholly Unique 3-Digit Dialing buy amoxil with free samples Code vs. An Existing N11 7.

We adopt our proposed two-step process to establish the scope of text messages that fall within our text-to-988 buy amoxil with free samples requirement (86 FR 31404, June 11, 2021). While we acknowledge the importance of testing and coordination between covered text providers and the Lifeline, we decline at this time to adopt the Department of Veterans Affairs' (VA's) proposed âthird-stepâ to our scope of text messages because the proposed testing and validation process is not germane to ex ante defining the scope of covered text providers. First, we establish an outer bound definition of â988 text messageâ that sets the maximum possible scope of text formats which covered text providers may be obligated to support for delivery to 988, based on the definition of âtext messageâ that Congress enacted in 2018 in the Truth in Caller ID context. Second, we establish a process to ensure that covered text providers only must enable transmission of text messages in formats that the Lifeline can buy amoxil with free samples actually receive. We also define the scope of entities subject to our text-to-988 requirementsâ i.e., âcovered text providersââto be consistent with our text-to-911 rules, which include Commercial Mobile Radio Services (CMRS) providers and providers of interconnected text messaging services.

We find that this approach, in combination, provides a forward-looking, flexible scope that will expand with the capabilities of the Lifeline without unnecessarily obligating covered text providers to support formats that the Lifeline cannot yet receive. 1 buy amoxil with free samples. Scope of Covered Text Formats 8. Outer Bound buy amoxil with free samples Definition. Consistent with our proposal in the further notice of proposed rulemaking (FNPRM) (86 FR 31404, June 11, 2021), we adopt the Truth in Caller ID definition of âtext messageââincluding the definitions for âshort message serviceâ (SMS) and, as a requirement when Lifeline is able to support it, âmultimedia message serviceâ (MMS)âas the outer bound scope of text messages that covered text providers may be obligated to transmit to 988, which provides that the term (1) means a message consisting of text, images, sounds, or other information that is transmitted to or from a device that is identified as the receiving or transmitting device by means of a 10-digit telephone number or N11 service code.

(2) includes a SMS message and a multimedia message service (commonly referred to as `MMS') message. And (3) buy amoxil with free samples does not includeâ(i) a real-time, two-way voice or video communication. Or (ii) a message sent over an internet protocol (IP)-enabled messaging service to another user of the same messaging service, except a message described in clause (2). 9. We find that there are buy amoxil with free samples several advantages to adopting the Truth in Caller ID definition in the text-to-988 context.

The definition encompasses, but is not exclusive to, SMS and MMS messages without limiting the outer bounds of supported text formats to specific technologies, thus providing flexibility for inclusion of future text message formats under the rules. It also represents a recent definition provided by Congress, albeit in a different policy context. We slightly modify the Truth in Caller ID definition to account for the 988 buy amoxil with free samples context by adopting our proposal to add âor 988â to the phrase from the Truth in Caller ID definition â10-digit telephone number or N11 service code.â This modification will ensure that covered text providers' obligations encompass those text messages sent to the Lifeline via the 3-digit code 988. We also add language clarifying that the definition we adopt âincludes and is not limited toâ SMS and MMS messages. This addition clarifies that the word âincludes,â within the definition we adopt, does not limit the scope of messages meeting the first prong of the definition and instead merely eliminates doubt buy amoxil with free samples as to whether SMS and MMS meet that definition.

The Truth in Caller ID definition expressly identifies that it includes images and sound. Allowing the parties that operate the Lifeline to incorporate graphics or other rich media in addition to textual communications, if they choose to do so, offers members of at-risk communities the means to communicate flexibly and fully with the Lifeline. Furthermore, the limitation of the initial implementation requirement to SMS messages, as discussed below, addresses CTIA and T-Mobile's concerns about meeting the implementation deadline if the Commission were to immediately require implementation of other text formats. The annual review process we establish below, through which the Wireline Competition Bureau (Bureau) will require covered text providers to implement only those texting formats within the outer bound definition that the Lifeline can actually receive, will ensure that covered text providers are not burdened with unnecessary work, and will avoid any consumer confusion that would arise from implementing formats that cannot go through. 11.

We clarify that the exclusions we adopt from the â988 text messageâ definition match those exclusions contained in the Truth in Caller ID âtext messageâ definition. We therefore exclude âreal-time, two-way voice or video communication[s],â as well as messages sent over âIP-enabled messaging service[s] to another user of the same messaging serviceâ that are not SMS or MMS messages. Similar to the Commission's interpretation in the Truth in Caller ID Second Report and Order (84 FR 45669, August 30, 20219), we conclude that âreal-time, two-way voice or video communicationâ includes voice calling service. We find that the plain language of the Truth in Caller ID exclusion indicates that Congress explicitly intended to exclude real-time, two-way video communication from the definition of âtext message. We further âinterpret the latter exclusion to include non-MMS or SMS messages sent using IP-enable Start Printed Page 401 messaging servicesâ between users of the same service.

For example, a message transmitted via an application delivered over IP-based networks, such as Twitter or LinkedIn, to another user of the same messaging service would be excluded from the outer bound definition. 12. We decline the Consumer Electronics Association's (CEA's) request to affirmatively determine at this time what particular text messaging formats fit within the outer bound definition. We direct the Bureau to resolve questions concerning the scope of the outer bound during the annual review process by applying the statutory Truth in Caller ID definition and Commission precedent regarding that definition. We clarify that should the Bureau find in the future based on the record before it that rich communications service (RCS), real-time text (RTT), or other formats do not fall within the exclusions from the 988 text message definition, then they may be acceptable formats within the outer bound scope.

We anticipate that addressing scope issues as they arise, in the context of specific technologies, will lead to better decisions based on more detailed information than trying to decide well ahead of any specific issue arising. 13. Limitation to Currently-Employed Technology. As proposed in the FNPRM, we initially require that covered text providers only support transmission of SMS messages to 988. We adopt the proposed procedure delegating to the Bureau future determinations to require covered text providers to support additional text formats within the outer bound definition, in consultation with our Federal partners and in consideration of what text formats the Lifeline is capable of receiving.

We therefore define âcovered 988 text messageâ as a 988 text message in SMS format and any other format that the Wireline Competition Bureau has determined must be supported by covered text providers. 14. The record supports requiring transmission of texts to 988 in SMS format. Vibrant indicates that the Lifeline can currently receive and respond to SMS messages sent to the 10-digit number. Furthermore, representatives of covered text providers and public interest groups express support for requiring transmission of SMS messages to 988.

In their support for adoption of requirements based on the Commission's text-to-911 rules, CTIA and T-Mobile note the technical feasibility of supporting SMS messages to 988, given that that format is currently supported in texting to 911. CEA also argues that the Commission should, at a minimum, require transmission of text messages in SMS within its broader outer bound definition. Because there is no technical or operational impediment to transmitting SMS messages to 988 expressed by covered text providers, and the Lifeline is currently able to receive and respond to SMS messages, we require covered text providers to support SMS messages to 988. 15. We decline at this time to require covered text providers to support other text message formats, such as MMS, RCS, and RTT, because the Lifeline cannot currently receive texts in these formats.

The Bureau will consider requiring covered text providers to support these or other additional formats through the Public Notice process we discuss below, should the Lifeline indicate it can receive such formats. While commenters note that rich media communications and next-generation text formats may offer benefits to individuals attempting to access the Lifeline, requiring covered text providers to transmit messages in these formats is premature because we do not know if or when the Lifeline will accept these formats. In addition, as CTIA states, including additional text formats such as RTT and RCS in the scope of our text-to-988 requirements âwould cause consumer confusion when the Lifeline is only capable of receiving SMS messages todayâ and, due to technical and engineering obstacles, would likely delay implementation of text-to-988 service. Finally, with respect to multimedia messages, both the Alliance for Telecommunications Industry Solutions (ATIS) and CTIA note that including media in text messages, a feature not currently supported in text-to-911 service, would present technical obstacles that could impede implementation by the July 16, 2022, deadline that we adopt. Although Vibrant indicates that the Lifeline is technically capable of receiving MMS formats, it clarifies that Lifeline policy and clinical standards âcurrently block[â] images and video from being seen by the counselor.â Because of the impediments to transmitting media such as images and video with text to 988, we decline to require covered text providers to support MMS messages to 988.

16. Just as our Federal partners recently added a texting capability to the Lifeline, they may choose to expand the functionality of their texting service over time. It is important for the requirements we establish to keep pace flexibly and readily rather than resorting to a Commission-level proceeding every time the Lifeline can accept a new text format. We therefore direct the Bureau to routinely consult with our Federal partners at SAMHSA and the VA to determine when the Lifeline has implemented a new text message format to 988. We further direct the Bureau, on or before June 30, 2023, and no less frequently than annually thereafter, to propose and seek comment on implementation parameters for covered text providers to transmit any additional text message formats to 988 that the Lifeline is capable of receiving and that are within the scope of the outer bound message definition adopted herein.

The Bureau shall identify the additional text messaging format(s) that the Lifeline is capable of receiving, if any. Propose and seek comment on an interpretive determination as to whether the additional text message format(s) fall within the outer bound definition. And propose and seek comment on implementation deadline(s) for those additional text message formats. If the Bureau finds after this process that the Lifeline is capable of receiving an additional text format that is within the scope of the outer bound definition that we have established, it shall release a second Public Notice requiring covered text providers to implement text-to-988 using that new format and setting an implementation date that is as prompt as reasonably practical. If the Bureau instead finds that, notwithstanding its initial proposal, the Lifeline is not capable of receiving an additional text format that is within the scope of the outer bound that we have established, it shall issue a Public Notice declining to adopt its initial proposal.

The Bureau may set one implementation deadline or staggered implementation deadlines for different classes of providers, and it shall identify all implementation deadlines with certainty ( i.e., by a specified calendar date). In setting a deadline or deadlines for compliance, the Bureau shall assess factors such as technical and financial challenges with respect to implementation, the status of the Lifeline, and the public interest. We find our two-step approach allows us to ensure rapid support for additional texting formats as technology evolves, while providing certainty to the industry and the public. Further, we find this approach facilitates further updates when the Lifeline implements a new texting format without requiring a Commission rulemaking, which often requires more time than Bureau-level action. Accordingly, we direct the Bureau to implement the approach we describe above, including through prescribing implementation deadlines.

Start Printed Page 402 17. CEA supports the Commission's proposal but asks for the Bureau to conduct annual public hearings rather than develop a written record. We find the proposed Public Notice procedure achieves the same purpose as a public hearingâproviding a forum to establish a record regarding expansion of the covered 988 text message definitionâwhile imposing fewer administrative burdens and costs on the public and the Commission. We expect the Bureau to meet with interested parties, as permitted by the Commission's ex parte rules. 18.

We also decline CEA's proposal that, should the Bureau or Commission require inclusion of RCS, RTT, or any other format, covered text providers would be required to support the new format âby the later of (i) three months after the Lifeline states that it is ready to receive such format. Or (ii) the date upon which the affected covered text provider begins providing such texting format to its customers generally.â We find it best to grant the Bureau flexibility to determine an implementation timeframe appropriate to each technology the Lifeline may implement. We prefer this approach because the Bureau will be able to make a decision based on a thorough record focused on the Lifeline's actual implementation of the technology. We anticipate that some technologies such as RTT that are already generally in use may be easier for covered text providers, especially larger providers, to support if implemented by the Lifeline, and we encourage the Bureau to take ease of implementation and availability of the technology into account when reaching a determination. 20.

We decline requests from CEA and ZP Better Together (ZP) to require direct video communication (DVC) and direct dialing from video relay service (VRS) to 988. With respect to VRS, ZP believes that by dialing 988 directly, both a Lifeline counselor and a VRS communications assistant would show up simultaneously. We are not addressing ZP's VRS request at this time because direct 988 dialing for VRS is beyond the scope of this item, which is focused on text-to-988. With respect to DVC, we strongly encourage the development and implementation of direct communications solutions for individuals with disabilities. However, the Lifeline does not receive direct communications via video.

Requiring providers to support communications that the Lifeline is not currently capable of receiving would cause consumer confusion, as individuals in crisis may attempt to access the Lifeline via direct video communications without realizing that the Lifeline cannot answer. We are pleased that the Lifeline is available to users of telecommunications relay services, including via 988, and the Lifeline maintains a separate TTY number, and we encourage our Federal partners to continue to consider additional alternative means by which individuals with disabilities may contact the Lifeline. Users of speech-to-speech services and TTY-based TRS dial 711 first to connect to a communications assistant who will complete the call to the Lifeline. 2. Definition of âCovered Text Providerâ 21.

We adopt our proposed definition of âcovered text providersâ as that term is defined in the Commission's text-to-911 rules, to include âall CMRS providers, as well as providers of interconnected text messaging services that enable consumers to send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones.â We find that the straightforward and well-established definition from the 911 context best delineates the scope of covered text providers obligated to support text-to-988 service. 22. The record supports our proposal to adopt the text-to-911 definition of âcovered text providerâ here. CTIA encourages us to keep the text-to-988 scope consistent with the scope of covered text providers in the text-to-911 context in order to âidentify a well-known and experienced scope of providers who will need to work collaboratively with the Lifeline to achieve the aggressive deadline that CTIA and others have suggested.â T-Mobile similarly agrees with CTIA that the Commission should look to its text-to-911 rules when establishing the scope of covered text providers in the text-to-988 context.

And, as CTIA notes, no commenter suggests an alternative definition to our proposal. 23. We require interconnected text messaging service providers, which enable customers to âsend text messages to all or substantially all text-capable U.S. Telephone numbers and receive text messages from the same,â to support text-to-988 service. We decline to apply our requirements to non-interconnected text providers, as CEA suggests.

By definition, non-interconnected text providers cannot send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, meaning they are unlikely to be able to transmit texts to and receive texts from 988. Even non-interconnected text providers that use telephone numbersâfor instance where an application uses telephone numbers to identify users relative to each other rather than for routingâmay nonetheless be unable to send text messages to users of other services or to all or substantially all telephone numbers. Obligating non-interconnected text providers to attempt to route texts to 988 via telephone numbers when physical routing is beyond such providers' control could increase customer confusion or diminish public trust in texting as a means to reach the Lifeline. 24.

Voice on the Net (VON) and Mitel request that we exempt covered text providers in Wi-Fi only locations because âthere remain challenges to the reliability of routing text messages to interconnected networks without the benefit of a CMRS provider.â We decline at this time to adopt a blanket exemption for covered text providers in Wi-Fi only locations. While we anticipate interconnected text messaging service providers will typically use CMRS-based solutions to support text-to-988, CMRS networks are not the only means of interconnection, and covered text providers may use any reliable method or methods to support text routing and transmission to 988. Furthermore, neither VON nor Mitel elaborate on or provide evidence to support their claims of technical challenges associated with routing without access to a CMRS network, or that such challenges cannot be bypassed by adopting a non-CMRS solution. While we agree with Mitel that â[r]outing messages to the interconnected network often requires access to an underlying wireless network or provider,â commenters have not provided sufficient support for us to Start Printed Page 403 conclude that covered text providers in Wi-Fi only locations are never able to use a CMRS-based or alternative method to reliably support text routing and transmission to 988. We reiterate that our requirements exclude providers that are unable to allow consumers to send text messages to and receive text messages from all or substantially all text-capable U.S.

Telephone numbers. C. Routing Texts to 988 25. We adopt our proposal to require covered text providers to route covered 988 text messages to the Lifeline's current 10-digit number, 1-800-273-8255 (TALK). Our decision is consistent with the Commission's approach in the 988 Report and Order (85 FR 57767, September 16, 2020) to require service providers to âtransmit all calls initiated by an end user dialing 988 to the current toll free access number for the Lifeline.â Most commenters support centralized routing for text-to-988.

26. We find our centralized routing rule will allow for swift implementation of text-to-988 to the Lifeline's 10-digit number by lowering technical requirements and costs for covered text providers to route texts to the Lifeline. As Vibrant states, our centralized routing solution for text-to-988 will âallow[] for a seamless delivery of crisis intervention services that is consistent with clinical standards, best practices, and national guidelines overseen by the administrator and SAMHSA.â CTIA notes that by requiring centralized routing, âthe Commission can significantly lower technical hurdles to enable wireless providers to deploy text-to-988 as soon as possible.â ATIS âhas not identified any technical challenges associated withâ routing covered 988 texts to the Lifeline 10-digit number. We note that several wireless providers were able to implement routing calls to 988 within six months of adoption, and we anticipate that similarly swift implementation may be possible here. 27.

We also find that adopting our proposal will provide our Federal partners with the flexibility to develop and expand routing solutions to meet the Lifeline's needs. Once text messages are routed to the Lifeline's 10-digit number, the Lifeline can then âforward those messages to the appropriate local crisis center,â similar to the current mechanism for voice call routing to 988. Currently, the Lifeline's network consists of over 180 crisis centers, with 33 centers providing text service. SAMHSA has identified resource strain and capacity issues experienced during its rollout of text service to the Lifeline's 10-digit number and, as a result, indicates its intention to explore working with existing crisis text and chat services outside the Lifeline as well as expanding text capacity within the network. We encourage SAMHSA and the VA to work with outside entities as needed to meet increased demand, and we believe our centralized routing rule will better allow for the Lifeline's network to adapt, evolve, and expand as necessary to meet capacity and technological needs.

28. We decline to require covered text providers to route covered 988 text messages directly to a Lifeline local crisis center or Veterans Crisis Line crisis center. While text-to-911 uses such direct routing, we believe that approach would be counterproductive for text-to-988. We disagree with Intrado's proposal to leverage the existing text-to-911 infrastructure by using Intrado's Text Control Center (TCC) services to transmit texts to 988 directly to an individual local crisis center, once the crisis center has made a valid request for text-to-988 service. This proposal mirrors the text-to-911 rules, where a covered text provider must enable text-to-911 service within six months of a local Public Safety Answering Point's (PSAP's) valid request for service.

In contrast, there are significant differences between 988 and 911, chief among them the nationwide Lifeline voice and text service routed through a centralized, toll free 10-digit number as opposed to the localized PSAP network. 29. We find that it is premature to require covered text providers to enable covered 988 text messages to include location information. As instructed by Congress in the National Suicide Hotline Designation Act of 2020, in April 2021 the Bureau released a report on the costs and feasibility of providing location information with calls to 988. In the report, the Bureau recommended the establishment of a multi-stakeholder advisory committee to develop detailed recommendations on how to address several challenges presented in the record, including privacy considerations, technical implementation, and cost recovery.

NAMI and Vibrant reiterate arguments raised in the 988 Geolocation Report that requiring geolocation information with calls and texts to local crisis centers will improve accuracy in connecting individuals in crisis with counselors who are in the best position to provide localized care. Yet, as the Bureau identified in the 988 Geolocation Report, requiring providers to transmit location information to 988 âraises important privacy and legal issues, is technically complex, and could impose significant costs.â Several commenters, including ATIS and CTIA, highlight the challenges identified in the 988 Geolocation Report and oppose a location information requirement for text-to-988, indicating it would be premature for the Commission to adopt such a mandate without further study and standards development. Given the similar complexity and interrelation between call and text routing to 988, we decline, at this time, NAMI and Vibrant's requests to require location information with texts transmitted to 988. Commenters also raise privacy concerns should the Commission require the transmission of location information without the texter's consent. Given the Bureau's recommendation and the similar concerns raised in the record regarding technical limitations of providing location information, we decline, at the present time, to require covered text providers to include location information with texts to 988.

30. We also decline to require covered text providers to take action to route texts to 988 to the Veterans Crisis Line, and we instead defer to our Federal partners to determine whether and how to make it possible to text 988 for the Start Printed Page 404 Veterans Crisis Line's text service. Telephone callers to the Lifeline's 10-digit number can press â1â to connect directly with a crisis counselor at the Veterans Crisis Line. Texting, on the other hand, is not presently integratedâtexters who wish to reach the Veterans Crisis Line contact a text short code (838255) rather than the Lifeline's toll free 10-digit number. We recognize that there would be significant benefits to enabling texters to reach the Veterans Crisis Line by texting 988.

Nor does the record reveal any solutions for requiring providers to implement texting to 988 for the Veterans Crisis Line's text service that we could effectuate in conjunction with requiring providers to implement texting to 988 for the Lifeline. After evaluation and testing, our Federal partners may be able to pursue a workable, reliable approach to enabling texts to 988 to reach the Veterans Crisis Line. At the present time, Service Members, Veterans, and their families may reach the Veterans Crisis Line by calling 1-800-273-8255 and pressing 1, by texting 838255, or by chat through the Veterans Crisis Line's website, https://www.veteranscrisisline.net. We recognize that during the rollout and launch of 988, our Federal partners at the VA will face challenges in promoting widespread public awareness that the Veterans Crisis Line is reachable by text through a short code that is separate from 988. We direct Commission staff to work cooperatively with our Federal partners to promote awareness of how Service Members, Veterans, and their families can reach the Veterans Crisis Line.

D. Implementation Timeframe 31. We adopt our proposal to set a uniform nationwide implementation deadline for text-to-988 of July 16, 2022âconcurrent with 988's voice implementation deadlineâfor all covered text providers to support transmission of all covered 988 text messages. As stated above, this deadline applies only to texts the user sends to 988. It does not apply to texts to the Veterans Crisis Line using its existing short code.

Guiding our decision is the need to minimize the time needed to implement text-to-988 so as to help address the growing epidemic of suicide as quickly as possible. By setting a uniform deadline, rollout of text-to-988 will be most effective, enabling stakeholders to clearly and consistently communicate when the public can access texting services universally, while avoiding any confusion stemming from a different deadline than voice implementation. Although a phased-in approach may enable us to set a shorter deadline for some providers, this approach risks confusion not just among those âunaware of the details of staggered regulatory deadlines,â but also among those who may seek to call rather than text. Such a scenario âcould be disastrous for individuals and, in the aggregate, could erode trust in the Lifeline.â Further, we find that a July 16, 2022, deadline provides the Lifeline adequate time to prepare for additional texting volume, with Vibrant expressing confidence following its successful 2021 pilot program that âthe Lifeline has the capability to receive text-to-988 messages on the first day of 988 operation.â And as ATIS highlights, because we only require that covered text providers send text messages to the Lifeline's 10-digit number, the need for a phased approach is eliminated. 32.

As the Mental Health Associations state, â[d]elaying an implementation deadline [beyond July 2022] will not prevent people in crisis from reaching out to 988 through text,â and such individuals will find their â[r]equest for help will go unansweredâ without action in this proceeding. 33. We reject VON's arguments that we should set a deadline of 12 months following the effective date of the order due to â[t]he need to develop and implement new routing and technical standardsâ that may pose challenges to meeting the voice deadline of July 16, 2022. Specifically, VON compares the Lifeline's call centers to PSAPs, explaining how in the context of text-to-911, a new joint standard needed to be created in order to direct texts to the latter. However, as explained above, we do not require that providers route texts to individual call centers, but instead to the Lifeline's toll free 10-digit number.

Additionally, VON cites these potential challenges only in vague terms, and claims only that they âmightâ serve as obstacles to âmeeting the voice deadline of July 16, 2022.â Moreover, as explained below, the flexible text-to-988 rules we adopt in this document do not generate significant technical obstacles, and the record's support for a July 16, 2022, deadline suggests that the issues pertinent to a texting solution specifically can be overcome in the given timeframe. For example, ATIS supports a July 16, 2022, deadline as âreasonableâ given that âit is already possible to text the existing Lifeline toll-free number,â highlighting that âtexting to the new three-digit short code (988) would create no new technical challenges.â E. Technical Considerations 34. We adopt our proposal to allow covered text providers to use any reliable method or methods to support text routing and transmission to 988. We reiterate that covered text providers may use any reliable method or methods to support text routing and transmission to 988, and emphasize our neutrality on the technologies that covered text providers use to support text messaging to 988.

We find that this approach accounts for currently-available text messaging formats and technologies and also provides the flexibility to adapt to future availability. No commenter opposed our proposal. As ATIS explains, texting to 988 âcan and should be implemented in a timely manner[,]â Start Printed Page 405 and should âcreate no technical challenges.â 35. Network Upgrades. Based on the record, we do not expect that covered text providers will need to install significant network upgrades to implement the texting to 988 requirements adopted herein.

We find, based on the record, that no significant software or equipment upgrades will be necessary to implement texting to 988. We agree with ATIS, one of the organizations that set the standards for texting to 911, that â[a] focus on functionality rather than technical standards is required to meet the needs of those who communicate primarily via texting.â We are not persuaded by VON's argument that, like implementing text-to-911, industry needs to develop new routing and technical standards that may delay text-to-988's implementation. VON generically states that 911 networks and the Lifeline are âtwo distinct infrastructuresâ that will require new standards, but does not explain why these infrastructural differences merit developing new standards. We find more convincing ATIS's assertion that changes to industry standards will âbe minimal if, as expected, no changes are required to consumer devices to support text-to-988 requirementsâ because the bulk of the record indicates that texting to 988's centralized routing solution, limited scope of text messaging service technologies, and other adopted requirements are straightforward to implement by our adoption deadline. 37.

We exempt legacy devices that are incapable of sending text messages via 3-digit codes from the text-to-988 requirements, provided the software for these devices cannot be upgraded over the air to allow text-to-988. In the Text-to-911 proceeding, the Commission did not require certain legacy devices to comply with the text-to-911 requirements because âthe messaging application or interface on the mobile device will likely provide an error message indicating an invalid destination number, reducing user confusion somewhatâ that the legacy device could not support texting to 911. No commenter discussed legacy devices nor indicated that circumstances have changed since the Commission adopted this exemption in the Text-to-911 proceeding. Accordingly, we find that the same exemption is appropriate here. 38.

Network Access. We require CMRS providers to allow access to their SMS networks by any other covered text provider for the capabilities necessary to transmit 988 text messages originating on such other covered text providers' networks, similar to the text-to-911 rules. We find this rule is necessary to implement our text to 988 requirement as we anticipate that many interconnected text providers will choose CMRS network-based solutions to implement texting to 988. No commenter opposed providing this network access. Mitel explains that, like in the texting to 911 context, routing messages to interconnected networks often requires access to an underlying wireless network and provider.

Similar to the text-to-911 rules, we adopt this requirement to ârespond to consumers' reasonable expectations and reduce consumer confusionâ regarding text-to-988's availability. 39. Similar to the Commission's position in the Text-to-911 Second Report and Order (79 FR 55367, September 14, 2014), we conclude that it is the responsibility of the covered text provider using the CMRS-based solution to ensure that its text messaging service is technically compatible with the CMRS providers' SMS-based network and devices and in conformance with any applicable technical standards. As in the text-to-911 context, we further require CMRS providers to make any necessary specifications for accessing their SMS networks available to other covered text providers upon request, and to inform such covered text providers in advance of any changes to these specifications. We clarify, however, that we do not intend to use these requirements to establish an open-ended obligation for CMRS providers to maintain underlying SMS network support merely for the use of other providers, nor do we require CMRS providers to reconfigure any SMS text-to-988 platforms in order to facilitate the ability of other covered text providers to access the CMRS providers' networks.

Further, as with the text-to-911 rules, CMRS providers' obligation to allow access to CMRS networks âis limited to the extent that the CMRS providers offers SMS.â While we expect that adopting these rules will similarly encourage âinterconnected text providers to actively develop solutions to support [text-to-988] without reliance on CMRS providers' underlying networks,â we nonetheless encourage providers to enact solutions to carry other covered text providers' text messages to 988 over their networks. F. Other Issues 40. Cost Recovery. We adopt our proposal to require all covered text providers to bear their own costs to implement text-to-988.

We find that this approach promotes efficiency in implementation and avoids unnecessary administrative costs. In the 988 Report and Order, we observed that â[u]nlike previous numbering proceedings in which the Commission established a cost recovery mechanism,â implementation of 988 itself does not involve âshared industry costs such as central or regional numbering databases or third-party administrators.â Similarly, we conclude that implementation of a text-to-988 solution requires no shared industry costs, with costs being provider-specific and solutions unique to each. As such, as proposed in the FNPRM we find that the requirements in section 251(e)(2) of the Act that â[t]he cost of establishing telecommunications numbering administration arrangements and number portability shall be borne by all telecommunications carriers on a competitively neutral basisâ does not apply. 41. Bounce-back Messages.

We decline to require covered text providers to send an automatic bounce-back message specifically designed to address where text-to-988 service is unavailable for several reasons. First, the record indicates that failed messages are likely to be rare. CTIA explains that network failures are ârare due to redundancies in the SMS networkâ and Vibrant indicates that to date the Lifeline's text messaging service has not experienced any downtime. Second, in the rare instance that covered text providers fail to deliver a text message to the Lifeline, current notice practices are sufficient. Individuals texting the Lifeline currently receive a bounce-back message under a variety of circumstances.

CTIA explains that covered text providers usually send customers a notification from a device or network when a CMRS provider cannot deliver a text message due to a network failure. Vibrant also indicates that the Lifeline currently sends individuals scheduled text messages approximately every 10 minutes if there is a wait to reach a crisis counselor that informs them they are in the queue, offers access to other Start Printed Page 406 resources while they wait, and provides the option to call the Lifeline. Consequently, we further agree with commenters that to the extent operational concerns, network congestion, or outsized demand prevent texters from reaching a crisis counselor, the parties that operate the Lifeline are in the best position to send a message to texters because covered text providers do not have visibility into the Lifeline's operations. Third, we decline to require 988-specific bounce-back messages because such a mandate risks delay of text-to-988 implementation. We recognize comments from CTIA which state that developing a bounce-back messaging capability âwould require substantial additional time and complexity, as well as the development of standards and requirements for implementation, and would significantly delay the July 16, 2022 implementation target.â T-Mobile further asserts that when a CMRS provider has not delivered a text message to the Lifeline due to network congestion, sending a Lifeline-specific automatic bounce-back message could be technically infeasible because â[c]arriers cannot determine if a text sent to the 10-digit Lifeline number has not been delivered due to network congestion or other factors related to nature of SMS generally.â 42.

Finally, a key circumstance that prompted the Commission to require automatic bounce-back messaging for text-to-911 are not present for text-to-988. In the Text-to-911 proceeding, the Commission adopted an automatic bounce-back messaging requirement because texting was and is only available to some PSAPs, and Americans in many parts of the country could not text 911 at all. In contrast, our centralized routing approach ensures that texting to 988 will be uniformly available nationwide. The unique geographic gaps that the bounce-back requirement addresses in the 911 context are not present here. It is possible that, as in the text-to-911 context, requiring a bounce-back message for text-to-988 could help âpersons in emergency situations being able to know immediately if a text message has been delivered to the proper authoritiesâ in the limited situations when consumers cannot send text messages to the Lifeline.

However, given the urgency of improving access to lifesaving suicide prevention resources, and in light of existing protections against and in the event of a delivery failure, we decline to a bounce-back messaging requirement for text-to-988 at this time. We will monitor the operation of texting to 988 post-implementation and will not hesitate to revisit the issue of requiring a bounce-back if warranted. 43. Federal Coordination. We direct the Bureau to continue to coordinate implementation of 988 with SAMHSA, including any issues pertaining to the delivery of text messages to 988.

We direct the Bureau and Commission staff to support the VA in promoting awareness of texting options for Service Members, Veterans, and their families, and to support the VA and SAMHSA in piloting, testing, and implementing any solution our Federal partners may choose to pursue to allow texting to 988 for the Veterans Crisis Line's text service. We also encourage SAMHSA to continue to work to expand the Lifeline's texting infrastructure. We will continue to work with and support our Federal partners in their efforts to assist Americans in crisis. 44. Future Technical Corrections to Lifeline 10-Digit Number.

We conclude that Title III of the Act and the Twenty-First Century Communications and Video Accessibility Act (CVAA) provide us with authority for the rules we adopt in this document. No commenter opposes these conclusions. With respect to CMRS providers, we find that Title III provides us the authority to require wireless carriers to enable and support text-to-988 service. Consistent with the U.S. Supreme Court's recognition that Title III provides the Commission a âbroad mandateâ to manage spectrum usage in the public interest, we find that significant public interest benefits will likely inure from broadly enabling access to lifesaving services through texting.

Further, the rules adopted here are analogous to those the Commission adopted to facilitate text-to-911, which relied in part on the Commission's Title III authority. Therefore, with respect to CMRS providers, we conclude that Title III provides sufficient authority for the rules we adopt in this document. 46. As to interconnected text messaging service providers, the CVAA granted us authority to adopt âother regulations. .

. As are necessary to achieve reliable, interoperable communication that ensures access by individuals with disabilities to an internet protocol-enabled emergency network.â We conclude that the Lifeline constitutes an âemergency networkâ within the meaning of the CVAA. The CVAA does not define what an âemergency networkâ is, nor does it elaborate on what qualifies as âemergency services.â However, Congress, through the National Suicide Hotline Designation Act, deemed âlife-saving resourcesâ such as the Lifeline and the Veterans Crisis Line âessentialâ and recognized the need for an âeasy-to-remember, 3-digit phone numberââthat is, one readily available in an emergency situation. As CTIA argues, it is therefore reasonable to conclude that such services should be considered âemergency servicesâ and that the Lifeline and Veterans Crisis Line act as an âemergency networkâ within the meaning of the CVAA. Moreover, texting capabilities provide âeasy access to emergency services for people with disabilities,â including those with hearing and speech disabilities.

Consistent with our proposal in the FNPRM, we find that benefits of requiring service providers to support text-to-988 far exceed the costs of implementation. The loss of victims' lives to suicide cannot be adequately captured by any pecuniary measure. The principal benefit of text-to-988 is that it will reduce suicide risk by providing an additional means of reaching help for the most vulnerable. Text-to-988 will reduce the risk of suicide mortality, primarily among those who would either send a text to 988 or forgo a lifesaving intervention altogether. Three vulnerable communities, in particular, face this stark choice.

Youth, who rely heavily on text messages for their general communications needs. The deaf, deafblind, hard of hearing, and speech disabled. And those who are reluctant to dial 988 because they feel unsafe, ashamed or embarrassed, including many LGBTQ+ youth and victims of domestic abuse. As outlined Start Printed Page 407 above, the ability to text to the short and easy-to-remember 988 code will make the lifesaving interventions of the Lifeline crisis centers even more accessible than dialing alone. As no commenter in the record disputes, we find that the benefits of implementing text-to-988 will quickly exceed costs, and dwarf them over time.

48. In the FNPRM, we estimated the cost of implementing text to 988 would be nearly $27 million over five years. We based our estimate on Intrado's existing estimates of the costs of upgrading 911 call centers to receive text messages. Although one commenter asserts that the costs of implementation are likely to be âsubstantially lowerâ than our estimate, no commenters provided any individual estimates or disputed our underlying approach or our estimate of the combined total cost of nearly $27 million with an alternate figure. We agree that implementation costs may be lower than we projected.

However, since no commenter provided an estimate of the impact of these potential reductions, we find it prudent to rely on our original estimate. 49. Commenters suggest quantifiable benefits that would greatly exceed these costs. For example, the Mental Health Associations emphasize that improved access to âmental health response to mental health crisesâ will result in cost savings for communities and individuals. These â[e]mergency department visits for mental health and substance use disorders cost an average of $520 across 10.7 million visits in 2017, for a total cost nationwide of nearly $5.6 billion.â Any reduction in these visits and resulting cost savings are benefits of implementing text-to-988.

In addition, the Center for Law and Social Policy (CLASP) points to an evaluation of Nevada's TextToday pilot program, one of the country's first crisis response lines that accepted text messages. The evaluation found an increase in help-seeking by youth and a preference for texting. Groups that would be especially likely to benefit from text-to-988 are members of the LGBTQ+ community, and deaf, deafblind, hard of hearing, and speech-disabled adults. Between 2015 and 2019, we estimate there were more than 39,000 suicides among youth 10-19, LGBTQ+ adults, and deaf, deafblind, hard of hearing, and speech-disabled adults. If text-to-988 reduces the annual risk of suicide mortality among these groups and others by even a very small amount, the benefits would easily outweigh the costs of implementing text-to-988.

II. Final Regulatory Flexibility Analysis 1. As required by the Regulatory Flexibility Act of 1980, as amended (RFA), an Initial Regulatory Flexibility Analysis (IRFA) was incorporated into the FNPRM, released April 2021. The Commission sought written public comments on the proposals in the FNPRM, including comment on the IRFA. No comments were filed addressing the IRFA.

Because the Commission amends its rules in the Second Report and Order, the Commission has included this Final Regulatory Flexibility Analysis (FRFA). This present FRFA conforms to the RFA. A. Need for, and Objectives of, the Rules 2. In the Second Report and Order, the Commission adopts rules requiring CMRS providers and providers of interconnected text messaging services that enable consumers to send text messages to, and receive text messages from, all or substantially all text-capable U.S.

There were no comments filed that specifically addressed the proposed rules and policies presented in the IRFA. C. Response to Comments by the Chief Counsel for Advocacy of the Small Business Administration 4. Pursuant to the Small Business Jobs Act of 2010, which amended the RFA, the Commission is required to respond to any comments filed by the Chief Counsel for Advocacy of the Small Business Administration (SBA), and to provide a detailed statement of any change made to the proposed rules as a result of those comments. 5.

The Chief Counsel did not file any comments in response to the proposed rules in this proceeding. D. Description and Estimate of the Number of Small Entities to Which the Rules Will Apply 6. The RFA directs agencies to provide a description of, and where feasible, an estimate of the number of small entities that may be affected by the final rules adopted pursuant to the Second Report and Order. The RFA generally defines the term âsmall entityâ as having the same meaning as the terms âsmall business,â âsmall organization,â and âsmall governmental jurisdiction.â In addition, the term âsmall businessâ has the same meaning as the term âsmall-business concernâ under the Small Business Act.

A âsmall-business concernâ is one which. (1) Is independently owned and operated. (2) is not dominant in its field of operation. And (3) satisfies any additional criteria established by the SBA. 7.

8. Next, the type of small entity described as a âsmall organizationâ is generally âany not-for-profit enterprise which is independently owned and operated and is not dominant in its field.â The Internal Revenue Service (IRS) uses a revenue benchmark of $50,000 or less to delineate its annual electronic filing requirements for small exempt organizations. Nationwide, for tax year 2018, there were approximately 571,709 small exempt organizations in the U.S. Reporting revenues of $50,000 or less according to the registration and tax data for exempt organizations available from the IRS. 9.

Finally, the small entity described as a âsmall governmental jurisdictionâ is defined generally as âgovernments of cities, counties, towns, townships, villages, school districts, or special districts, with a population of less than fifty thousand.â U.S. Census Bureau data from the 2017 Census of Governments indicate that there were 90,075 local governmental jurisdictions consisting of general purpose Start Printed Page 408 governments and special purpose governments in the United States. Of this number there were 36,931 general purpose governments (county, municipal and town or township) with populations of less than 50,000 and 12,040 special purpose governmentsâindependent school districts with enrollment populations of less than 5ll governmental jurisdictions. 10. Wired Telecommunications Carriers.

The U.S. Census Bureau defines this industry as âestablishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired communications networks. Transmission facilities may be based on a single technology or a combination of technologies. Establishments in this industry use the wired telecommunications network facilities that they operate to provide a variety of services, such as wired telephony services, including [voice over internet protocol] VoIP services, wired (cable) audio and video programming distribution, and wired broadband internet services. By exception, establishments providing satellite television distribution services using facilities and infrastructure that they operate are included in this industry.â The SBA has developed a small business size standard for Wired Telecommunications Carriers, which consists of all such companies having 1,500 or fewer employees.

Local Exchange Carriers (LECs). Neither the Commission nor the SBA has developed a size standard for small businesses specifically applicable to local exchange services. The closest applicable North American Industry Classification System (NAICS) Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S.

Census Bureau data for 2012 show that there were 3,117 firms that operated for the entire year. Of that total, 3,083 operated with fewer than 1,000 employees. Thus under this category and the associated size standard, the Commission estimates that the majority of local exchange carriers are small entities. 12. Incumbent Local Exchange Carriers (Incumbent LECs).

Neither the Commission nor the SBA has developed a small business size standard specifically for incumbent local exchange services. The closest applicable NAICS Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated the entire year.

13. Competitive Local Exchange Carriers (Competitive LECs). Competitive Access Providers (CAPs), Shared-Tenant Service Providers, and Other Local Service Providers. Neither the Commission nor the SBA has developed a small business size standard specifically for these service providers. The appropriate NAICS Code category is Wired Telecommunications Carriers and under that size standard, such a business is small if it has 1,500 or fewer employees.

U.S. Census Bureau data for 2012 indicate that 3,117 firms operated during that year. Of that number, 3,083 operated with fewer than 1,000 employees. Based on these data, the Commission concludes that the majority of Competitive LECS, CAPs, Shared-Tenant Service Providers, and Other Local Service Providers, are small entities. According to Commission data, 1,442 carriers reported that they were engaged in the provision of either competitive local exchange services or competitive access provider services.

Of these 1,442 carriers, an estimated 1,256 have 1,500 or fewer employees. In addition, 17 carriers have reported that they are Shared-Tenant Service Providers, and all 17 are estimated to have 1,500 or fewer employees. Also, 72 carriers have reported that they are Other Local Service Providers. Of this total, 70 have 1,500 or fewer employees. Consequently, based on internally researched FCC data, the Commission estimates that most providers of competitive local exchange service, competitive access providers, Shared-Tenant Service Providers, and Other Local Service Providers are small entities.

14. Interexchange Carriers (IXCs). Neither the Commission nor the SBA has developed a small business size standard specifically for Interexchange Carriers. The closest applicable NAICS Code category is Wired Telecommunications Carriers. The applicable size standard under SBA rules is that such a business is small if it has 1,500 or fewer employees.

U.S. Census Bureau data for 2012 indicate that 3,117 firms operated for the entire year. Of that number, 3,083 operated with fewer than 1,000 employees. According to internally developed Commission data, 359 companies reported that their primary telecommunications service activity was the provision of interexchange services. Of this total, an estimated 317 have 1,500 or fewer employees.

Consequently, the Commission estimates that the majority of interexchange service providers are small entities. 15. Local Resellers. The SBA has not developed a small business size standard specifically for Local Resellers. The SBA category of Telecommunications Resellers is the closest NAICS code category for local resellers.

The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. Mobile virtual network operators (MVNOs) are included in this industry. Under the SBA's size standard, such a business is small if it has 1,500 or fewer employees.

Of these, an estimated 211 have 1,500 or fewer employees and two have more than 1,500 employees. Consequently, the Commission estimates that the majority of local resellers are small entities. 16. Toll Resellers. The Commission has not developed a definition for Toll Resellers.

The closest NAICS Code Category is Telecommunications Start Printed Page 409 Resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. MVNOs are included in this industry.

The SBA has developed a small business size standard for the category of Telecommunications Resellers. Under that size standard, such a business is small if it has 1,500 or fewer employees. 2012 U.S. Census Bureau data show that 1,341 firms provided resale services during that year. Of that number, 1,341 operated with fewer than 1,000 employees.

Other Toll Carriers. Neither the Commission nor the SBA has developed a definition for small businesses specifically applicable to Other Toll Carriers. This category includes toll carriers that do not fall within the categories of interexchange carriers, operator service providers, prepaid calling card providers, satellite service carriers, or toll resellers. The closest applicable size standard under SBA rules is for Wired Telecommunications Carriers. The applicable SBA size standard consists of all such companies having 1,500 or fewer employees.

U.S. Census Bureau data for 2012 indicates that 3,117 firms operated during that year. Of that number, 3,083 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of Other Toll Carriers can be considered small. According to internally developed Commission data, 284 companies reported that their primary telecommunications service activity was the provision of other toll carriage.

Of these, an estimated 279 have 1,500 or fewer employees. Consequently, the Commission estimates that most Other Toll Carriers are small entities. 18. Prepaid Calling Card Providers. Neither the Commission nor the SBA has developed a small business definition specifically for prepaid calling card providers.

Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that 1,341 firms provided resale services during that year. Of that number, 1,341 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these prepaid calling card providers can be considered small entities.

According to the Commission's Form 499 Filer Database, 86 active companies reported that they were engaged in the provision of prepaid calling cards. The Commission does not have data regarding how many of these companies have 1,500 or fewer employees, however, the Commission estimates that the majority of the 86 active prepaid calling card providers that may be affected by these rules are likely small entities. 19. Wireless Telecommunications Carriers (except Satellite). This industry comprises establishments engaged in operating and maintaining switching and transmission facilities to provide communications via the airwaves.

Establishments in this industry have spectrum licenses and provide services using that spectrum, such as cellular services, paging services, wireless internet access, and wireless video services. The appropriate size standard under SBA rules is that such a business is small if it has 1,500 or fewer employees. For this industry, U.S. Census Bureau data for 2012 show that there were 967 firms that operated for the entire year. Of this total, 955 firms employed fewer than 1,000 employees and 12 firms employed of 1000 employees or more.

Thus under this category and the associated size standard, the Commission estimates that the majority of Wireless Telecommunications Carriers (except Satellite) are small entities. 20. The Commission's own dataâavailable in its Universal Licensing Systemâindicate that, as of August 31, 2018, there are 265 Cellular licensees that will be affected by our actions. The Commission does not know how many of these licensees are small, as the Commission does not collect that information for these types of entities. Similarly, according to internally developed Commission data, 413 carriers reported that they were engaged in the provision of wireless telephony, including cellular service, Personal Communications Service (PCS), and Specialized Mobile Radio (SMR) Telephony services.

Of this total, an estimated 261 have 1,500 or fewer employees, and 152 have more than 1,500 employees. Thus, using available data, we estimate that the majority of wireless firms can be considered small. 21. Cable and Other Subscription Programming. The U.S.

Census Bureau defines this industry as establishments primarily engaged in operating studios and facilities for the broadcasting of programs on a subscription or fee basis. The broadcast programming is typically narrowcast in nature ( e.g., limited format, such as news, sports, education, or youth-oriented). These establishments produce programming in their own facilities or acquire programming from external sources. The programming material is usually delivered to a third party, such as cable systems or direct-to-home satellite systems, for transmission to viewers. The SBA size standard for this industry establishes as small any company in this category with annual receipts less than $41.5 million.

Based on U.S. Census Bureau data for 2012, 367 firms operated for the entire year. Of that number, 319 firms operated with annual receipts of less than $25 million a year and 48 firms operated with annual receipts of $25 million or more. Based on this data, the Commission estimates that a majority of firms in this industry are small. 22.

In addition, under the Commission's rate regulation rules, a âsmall systemâ is a cable system serving 15,000 or fewer subscribers. Commission records show 4,600 cable systems nationwide. Of this total, 3,900 cable systems have fewer than 15,000 subscribers, and 700 systems have Start Printed Page 410 15,000 or more subscribers, based on the same records. Thus, under this standard as well, we estimate that most cable systems are small entities. 23.

Cable System Operators (Telecom Act Standard). The Communications Act of 1934, as amended, also contains a size standard for small cable system operators, which is âa cable operator that, directly or through an affiliate, serves in the aggregate fewer than one percent of all subscribers in the United States and is not affiliated with any entity or entities whose gross annual revenues in the aggregate exceed $250,000,000.â As of 2019, there were approximately 48,646,056 basic cable video subscribers in the United States. Accordingly, an operator serving fewer than 486,460 subscribers shall be deemed a small operator if its annual revenues, when combined with the total annual revenues of all its affiliates, do not exceed $250 million in the aggregate. Based on available data, we find that all but five cable operators are small entities under this size standard. We note that the Commission neither requests nor collects information on whether cable system operators are affiliated with entities whose gross annual revenues exceed $250 million.

Therefore, we are unable at this time to estimate with greater precision the number of cable system operators that would qualify as small cable operators under the definition in the Communications Act. 24. All Other Telecommunications. The âAll Other Telecommunicationsâ category is comprised of establishments primarily engaged in providing specialized telecommunications services, such as satellite tracking, communications telemetry, and radar station operation. This industry also includes establishments primarily engaged in providing satellite terminal stations and associated facilities connected with one or more terrestrial systems and capable of transmitting telecommunications to, and receiving telecommunications from, satellite systems.

Thus, the Commission estimates that the majority of âAll Other Telecommunicationsâ firms potentially affected by our action can be considered small. 25. Radio and Television Broadcasting and Wireless Communications Equipment Manufacturing. This industry comprises establishments primarily engaged in manufacturing radio and television broadcast and wireless communications equipment. Examples of products made by these establishments are.

Transmitting and receiving antennas, cable television equipment, Global Positioning System (GPS) equipment, pagers, cellular phones, mobile communications equipment, and radio and television studio and broadcasting equipment. The SBA has established a small business size standard for this industry of 1,250 employees or less. U.S. Census Bureau data for 2012 show that 841 establishments operated in this industry in that year. Of that number, 828 establishments operated with fewer than 1,000 employees, 7 establishments operated with between 1,000 and 2,499 employees and 6 establishments operated with 2,500 or more employees.

Based on this data, we conclude that a majority of manufacturers in this industry are small. 26. Semiconductor and Related Device Manufacturing. This industry comprises establishments primarily engaged in manufacturing semiconductors and related solid state devices. Examples of products made by these establishments are integrated circuits, memory chips, microprocessors, diodes, transistors, solar cells and other optoelectronic devices.

27. Software Publishers. This industry comprises establishments primarily engaged in computer software publishing or publishing and reproduction. Establishments in this industry carry out operations necessary for producing and distributing computer software, such as designing, providing documentation, assisting in installation, and providing support services to software purchasers. These establishments may design, develop, and publish, or publish only.

The SBA has established a size standard for this industry of annual receipts of $41.5 million or less per year. U.S. Census data for 2012 indicates that 5,079 firms operated for the entire year. Of that number 4,691 firms had annual receipts of less than $25 million and 166 firms had annual receipts of $25,000,000 to $49,999,999. Based on this data, we conclude that a majority of firms in this industry are small.

28. Internet Service Providers (Broadband). Broadband internet service providers include wired ( e.g., cable, digital subscriber line (DSL)) and VoIP service providers using their own operated wired telecommunications infrastructure fall in the category of Wired Telecommunication Carriers. Wired Telecommunications Carriers are comprised of establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired telecommunications networks. Transmission facilities may be based on a single technology or a combination of technologies.

29. Internet Service Providers (Non-Broadband). Internet access service providers such as dial-up internet service providers (ISPs), VoIP service providers using client-supplied telecommunications connections and internet service providers using client-supplied telecommunications connections ( e.g., dial-up ISPs) fall in the category of All Other Telecommunications. The SBA has developed a small business size standard for All Other Telecommunications which consists of all such firms with gross annual receipts of $35 million or less. For this category, U.S.

Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year. Of these firms, a total of 1,400 had gross annual receipts of less than $25 million. Consequently, under this size standard a majority of firms in this industry can be considered small. 30. All Other Information Services.

The U.S. Census Bureau has determined that this category âcomprises establishments primarily engaged in providing other information services (except news syndicates, libraries, archives, internet publishing and Start Printed Page 411 broadcasting, and Web search portals).â The SBA has developed a small business size standard for this category, which consists of all such firms with annual receipts of $30 million or less. U.S. Census Bureau data for 2012 show that there were 512 firms that operated for the entire year. Of those firms, a total of 498 had annual receipts less than $25 million and 7 firms had annual receipts of $25 million to $49,999,999.

Consequently, we estimate that the majority of these firms are small entities that may be affected by our action. E. Description of Projected Reporting, Recordkeeping, and Other Compliance Requirements for Small Entities 31. The Second Report and Order modifies the Commission's rules to require covered text providers to support text messaging to 988. It concludes that text-to-988 functionality will greatly improve consumer access to the Lifeline, particularly for at-risk populations and thereby save lives.

The final rules adopted in the Second Report and Order require CMRS providers and interconnected text messaging service providers to route texts sent to 988 to the 10-digit Lifeline number, presently 1-800-273-8255 (TALK). The Second Report and Order (1) establishes a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support. (2) directs the Wireline Competition Bureau (Bureau) to identify text formats within the scope of that definition that the Lifeline can receive and thus covered text providers must support by routing to the 10-digit Lifeline number. And (3) requires CMRS providers that offer SMS to allow access by any other covered text provider to the capabilities necessary for transmission of 988 text messages originating on such other covered text providers' application services. F.

Steps Taken To Minimize the Significant Economic Impact on Small Entities, and Significant Alternatives Considered 32. The RFA requires an agency to describe any significant, specifically small business, alternatives that it has considered in reaching its approach, which may include the following four alternatives (among others). Â(1) the establishment of differing compliance or reporting requirements or timetables that take into account the resources available to small entities. (2) the clarification, consolidation, or simplification of compliance and reporting requirements under the rules for such small entities. (3) the use of performance rather than design standards.

And (4) an exemption from coverage of the rule, or any part thereof, for such small entities.â 33. In the Second Report and Order, the Commission adopts a uniform implementation deadline for all covered text providers to route covered 988 text messages to 988 to the Lifeline's 10-digit number by July 16, 2022. The Commission believes that applying the same rules equally to all entities in this context is necessary to alleviate potential consumer confusion from adopting different rules, at different times, for different covered text providers. However, the Commission does not believe that the actions in the Second Report and Order will overly burden small carriers or providers. Further, the Commission believes that by its actions, all entities, including small carriers or providers, will benefit from reduced costs.

In addition, the Commission will send a copy of the Second Report and Order, including this FRFA, to the Chief Counsel for Advocacy of the SBA. A copy of the Second Report and Order and FRFA (or summaries thereof) will also be published in the Federal Register. III. Procedural Matters 35. Paperwork Reduction Act of 1995 Analysis.

This document does not contain proposed information collection(s) subject to the Paperwork Reduction Act of 1995 (PRA), Public Law 104-13. In addition, therefore, it does not contain any new or modified information collection burden for small business concerns with fewer than 25 employees, pursuant to the Small Business Paperwork Relief Act of 2002, Public Law 107-198, see 44 U.S.C. 3506(c)(4). 36. Final Regulatory Flexibility Analysis.

As required by the Regulatory Flexibility Act of 1980,103 the Commission has prepared a Final Regulatory Flexibility Analysis (FRFA) of the possible significant economic impact on small entities of the policies and rules, as proposed, addressed in the Second Report and Order. The FRFA is set forth in Appendix B of the Second Report and Order. The Commission will send a copy of the Second Report and Order, including the FRFA, to the Chief Counsel for Advocacy of the Small Business Administration (SBA). 37. Congressional Review Act.

People With Disabilities. To request materials in accessible formats for people with disabilities (braille, large print, electronic files, audio format), send an email to fcc504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at (202) 418-0530 (voice), 202-418-0432 (tty). 39. Contact Person.

For further information about this rulemaking proceeding, please contact Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388 or michelle.sclater@fcc.gov. IV. Ordering Clauses 40. Accordingly, it is ordered , pursuant to sections 201, 251(e)(4), 301, 303, 307, 309, 316, and 615c of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251(e)(4), 301, 303, 307, 309, 316, 615c, that the Second Report and Order in WC Docket No.

18-336 is adopted. 41. It is further ordered that, pursuant to Â§Â§â1.4(b)(1) and 1.103(a) of the Commission's rules, 47 CFR 1.4(b)(1), 1.103(a), the Report and Order shall be effective 30 days after publication in the Federal Register. 42. It is further ordered that part 52 of the Commission's rules is amended as set forth in Appendix A of the Second Report and Order.

43. It is further ordered that the Commission shall send a copy of the Second Report and Order to Congress and to the Government Accountability Office pursuant to the Congressional Review Act, see 5 U.S.C. 801(a)(1)(A). 44. It is further ordered that the Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, shall send a copy of the Second Report and Order, including the Final Regulatory Flexibility Analysis (FRFA), to the Chief Counsel for Advocacy of the Small Business Administration.

Start List of Subjects Start Printed Page 412 Communications common carriersTelecommunicationsTelephone End List of Subjects (47 U.S.C. 201, 251, 301, 303, 307, 309, 316) Start Signature Federal Communications Commission. Katura Jackson, Federal Register Liaison Officer. End Signature Final Rules For the reasons stated in the preamble, the Federal Communications Commission amends 47 CFR part 52 as follows. Start Part End Part Start Amendment Part1.

The authority citation for part 52 continues to read as follows. End Amendment Part Start Authority 47 U.S.C. 151, 152, 153, 154, 155, 201-205, 207-209, 218, 225-227, 251-252, 271, 303, 332, unless otherwise noted. End Authority Start Amendment Part2. Add Â§â52.201 to read as follows.

End Amendment Part Texting to the National Suicide Prevention and Mental Health Crisis Hotline. (a) Support for 988 text message service. Beginning July 16, 2022, all covered text providers must route a covered 988 text message to the current toll free access number for the National Suicide Prevention Lifeline, presently 1-800-273-8255 (TALK). (b) Access to SMS networks for 988 text messages. To the extent that Commercial Mobile Radio Services (CMRS) providers offer Short Message Service (SMS), they shall allow access by any other covered text provider to the capabilities necessary for transmission of 988 text messages originating on such other covered text providers' application services.

And (iii) Does not includeâ (A) A real-time, two-way voice or video communication. Or (B) A message sent over an IP-enabled messaging service to another user of the same messaging service, except a message described in paragraph (b) of this section. Covered 988 text message means a 988 text message in SMS format and any other format that the Wireline Competition Bureau has determined must be supported by covered text providers. Covered text provider includes all CMRS providers as well as all providers of interconnected text messaging services that enable consumers to send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones.

Multimedia message service ( MMS ) shall have the same definition as the term in Â§â64.1600(k) of this chapter. Short message service ( SMS ) shall have the same definition as the term in Â§â64.1600(m) of this chapter. End Supplemental Information [FR Doc. 2021-27878 Filed 1-4-22. 8:45 am]BILLING CODE 6712-01-P.

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ÂI must also remind you that increasing levels of social mixing where can you get amoxil provide the amoxil with the highest opportunity to spreadâ, he added. Although everyone is tired of hearing about buy antibiotics and its restrictions, âwe need to face an undeniable factâ¦the amoxil is still very much present among usâ, he added. ÂAnother stormâ rolling in WHOâs top official in Europe, Hans Kluge, also issued a statement against the backdrop of rising Omicron cases, revealing that last week, Europe and central Asia saw 27,000 additional buy antibiotics deaths and 2.6 million new cases.

Although s stem predominantly from the Delta variant, since its identification 27 days ago, Omicron has been detected where can you get amoxil in at least 38 of the 53 Member States in WHOâs European Region. ÂWe can see another storm coming â Omicron is becoming, or already has become, dominant in several countries, including in Denmark, Portugal and the United Kingdom, where its numbers are doubling every 1.5 to three days, generating previously unseen transmission ratesâ, he said. ÂThis variant can evade previous immunity in people â so it can still infect those who have had buy antibiotics in the past, those who are unvaccinated, and those who were vaccinated many months agoâ.

Furthermore, those who have recovered from buy antibiotics are three-to-five times more likely to be reinfected with Omicron, compared to Delta. Unsplash/Andrea De SantisLondon is facing a tidal wave of s from the new Omicron where can you get amoxil antibiotics variant.Protect and prevent On a positive note, early evidence supports the assumption that buy antibiotics treatments continue to do their job and save lives. Because the amoxil has been transmitted mostly among adults in their 20s and 30s, spreading in social and workplace gatherings, Dr.

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ÂIf you are unvaccinated â get the jab. If you have had buy antibiotics where can you get amoxil in the past â get the jab. If you are due a booster â get the jabâ.

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That message from the head of the World Health Organization (WHO) in buy amoxil with free samples Buy zithromax online canada the Eastern Mediterranean region, indicated that the amoxil is far from over, wherever you may live. Citing the latest modelling data, Ahmed Al-Mandhari said that 22 countries and territories in the region would probably see more than 17 million cases and over 314,000 deaths by the end of the year. Despite the holiday season, âfailure to apply the established public health and social measures could cause alarming surges in the number of buy antibiotics cases and related deathsâ, he said.

Follow buy antibiotics guidelines While the Omicron variant has already been found in 14 countries across the Middle East and eastern Mediterranean region, more research is needed before its impact on existing treatments, diagnosis and treatment, is fully understood, the WHO Regional buy amoxil with free samples Director explained. Âbuy antibiotics will continue to evolve in the months to come. Simply because the amoxil continues to mutateâ, he continued.

ÂThis is buy amoxil with free samples what amoxiles do. They change as they circulateâ. He underscored that following buy antibiotics prevention guidelines is âthe only way we can stop the amoxil from spreadingâ¦now more than everâ.

Three good buy amoxil with free samples reasons Dr. Al-Mandhari explained why everyone needs to stick to the guidelines. ÂFirst, the winter season has been characterized by spikes of cases and deaths.

Second, the holiday season with gatherings of friends and buy amoxil with free samples families. Third, the arrival of Omicron, which has the capacity to become a dominant variant in a matter of weeks wherever it emerges. ÂI must also remind you that increasing levels of social mixing provide the amoxil with the highest opportunity to spreadâ, he added.

Although everyone is tired of hearing about buy antibiotics and its restrictions, âwe need to face an undeniable factâ¦the amoxil is still buy amoxil with free samples very much present among usâ, he added. ÂAnother stormâ rolling in WHOâs top official in Europe, Hans Kluge, also issued a statement against the backdrop of rising Omicron cases, revealing that last week, Europe and central Asia saw 27,000 additional buy antibiotics deaths and 2.6 million new cases. Although s stem predominantly from the Delta variant, since its identification 27 days ago, Omicron has been detected in at least 38 of the 53 Member States in WHOâs European Region.

ÂWe can see another storm coming â Omicron is becoming, or already has become, dominant in several countries, including in Denmark, Portugal and the United Kingdom, where its numbers are doubling every 1.5 to three days, generating previously unseen transmission ratesâ, he said. ÂThis variant can evade previous immunity in people â buy amoxil with free samples so it can still infect those who have had buy antibiotics in the past, those who are unvaccinated, and those who were vaccinated many months agoâ. Furthermore, those who have recovered from buy antibiotics are three-to-five times more likely to be reinfected with Omicron, compared to Delta.

Unsplash/Andrea De SantisLondon is facing a tidal wave of s from the new Omicron antibiotics variant.Protect and prevent On a positive note, early evidence supports the assumption that buy antibiotics treatments continue to do their job and save lives. Because the amoxil has been transmitted mostly buy amoxil with free samples among adults in their 20s and 30s, spreading in social and workplace gatherings, Dr. Kluge, noted âthree things that we need to do urgentlyâ.

ÂProtect ourselves through vaccination, prevent further s, and prepare health systems for a surge in casesâ. He insisted on the importance of scaling buy amoxil with free samples up treatments for everyone. ÂIf you are unvaccinated â get the jab.

If you have had buy antibiotics in the past â get the jab. If you are due buy amoxil with free samples a booster â get the jabâ. Preparation Dr.

Kluge said that vaccinations should go forward along with other -prevention measures, such as avoiding crowded, closed, and confined spaces. Keeping physical distances buy amoxil with free samples. Washing hands.

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Welcome to the December edition of Emergency Medicine Journal, the final one for 2020 buy amoxil online cheap. This has been an âinterestingâ year for Emergency Physicians and their departments, with many changes to working practices. We hope you are keeping well in these uncertain times.Vascular accessThe Editorâs choice this month is a randomised controlled trial (Chauvin et al) wherein patients requiring blood gas buy amoxil online cheap measurement were randomised to arterial or venous sampling.

While the findings of less pain and increased ease for venous sampling might not be surprising, it is surprising that the clinical utility of the biochemical data (as assessed by treating physician) is equivalent. This provides further evidence to buy amoxil online cheap support the move to venous blood gases for most patients.Vascular access in paediatric patients is the focus of Girotto et alsâ paper, which validates predictive rules (DIVA and DIVA3) for difficult venous access. Of interest are the additional factors (nurse assessment of difficulty, and dehydration status of moderate severity or more) which identified difficult access when the rule had not predicted difficulty in siting a venous cannula.Targets.

Achievement and effectsThere has long been intense debate buy amoxil online cheap regarding the use of quality metrics to assess performance of Emergency Departments (cf the âGoodhart principleâ). A number of papers in this monthâs EMJ look at âtargetsâ- the effect the presence of targets can have, and the ramifications of attempts to achieve targets.Sethi et al have used a âbefore and afterâ study design to retrospectively assess the effect on Emergency Department Clinical Quality Indicators of hospital-wide interventions to improve patient flow through the hospital (the âReaderâs choiceâ for this month). An improvement buy amoxil online cheap in the Emergency Department quality indicators was demonstrated when a programme designed to improve patient flow through the hospital was undertaken.

The authors suggest that this programme may have resulted in a hospital-wide focus on the issue of âexit blockâ and this may have had a significant effect, by changing the âcultureâ of the hospital.This is complemented neatly by two further papers in this monthâs EMJ. First, Paling et al, looks at waiting times in buy amoxil online cheap Emergency Departments, using routinely collected hospital data. This paper suggests that higher bed occupancy, and higher numbers of long stay patients, increases the number of patients who remain in the Emergency Department beyond the â4âhour target (for England)â.

Second, Man et al studied the long waiting times for Emergency Medical Services (EMS), due to delayed handover from ambulance to the Emergency Department (referred to as âambulance rampingâ). The interventions within buy amoxil online cheap the Emergency Department designed to improve achievement of the â4âhour target (for Australia)â also reduced EMS wait times. As with the Sethi paper, improving patient flow has a wider reaching impact.Another paper related to this topic is a validation of the NEDOCS overcrowding score, by Hargreaves et al.

This paper assesses this tool buy amoxil online cheap against clinician perception of crowding and patient safety. The relationship between changes in overcrowding score and clinicianâs perception was assessed, and refinements to the score suggested. The differences between physician and nurse perceptions of crowding and safety are intriguing, however the buy amoxil online cheap âbottom lineâ may be that the search continues for the perfect scoring system for crowding.Mental health in the emergency departmentA cross-sectional study of Emergency Department attendances across England (Baracaia et al) is discussed in Catherine Hayhurstâs commentary.

This reminds us of the high prevalence of patients presenting with mental health symptoms to our departments, and stimulates thought about how we can better meet their needs. This is further illustrated by the papers looking at care pathways for patients with self-harm who use ambulance services (Zayed buy amoxil online cheap at al), and the mental health triage tool derived using a Delphi study by Mackway-Jones.Emergency departments and buy antibioticsThis month sees three papers related to buy antibiotics. Walton et al describe some of the key themes from an operational perspective, faced by UK Emergency Departments.

These themes will be familiar to many readers, as will some of the suggested buy amoxil online cheap solutions to the challenges.Choudhary and colleagues have looked at changes in clinical presentation of cardiovascular emergencies (acute coronary syndromes, rhythm disturbances and acute heart failure) and their management during the amoxil. While the changes in patient behaviour (eg, reduced attendance) are well known, the changes in clinician behaviour (eg, increased use of thrombolysis) are not.The third paper describes changing patterns of Paediatric attendances to Emergency Departments in Canada during the amoxil (Goldman et al). The findings here will chime with us all.A simple buy amoxil online cheap communication toolA personal favourite of mine (notwithstanding a conflict of interest!.

Involvement of patients in the analysis of the issue, patient-centred metrics, and a neat description of control charts and their use. Moreover, the simple âAEIâ communication tool buy amoxil online cheap described is one that I find elegant, effective and have adopted into my practice.Emergency mental health is part of our core business, although emergency department (ED) staff may have varying levels of comfort with this. We need to be as competent with the initial management of a patient with a mental health crisis as we are with trauma, sepsis or any other emergency.

To do this, we need compassion and empathy underpinned buy amoxil online cheap by systems and training for all our staff. Our attitudes to patients in crisis are often the key to improvements in care. If we are honest, some ED staff are fearful and worry that what they say may make buy amoxil online cheap a patient feel worse.

Others may resent patients who come repeatedly in crisis. It helps to consider these patients just buy amoxil online cheap as we would patients with asthma or diabetes who may also come âin crisisâ. Our role is to help get them through that crisis, with kindness and competence.A detailed look at Hospital Episode Statistics (HES) for England 2013/2014 by Baracaia et al in EMJ show that 4.9% of all ED attendances were coded as having a primary mental health diagnosis.1 Cumulative HES data have shown an average increase in mental health attendances of 11% per year since 20132 (figure 1) far in excess of total ED attendance increase (figure 2).

National data from the USA show a 40.8% increase in ED visits for adult with a mental health presentation from 2009 to 2015.3 US paediatric visits for the same period rose by 56.5%3 and a worrying 2.5-fold increase over 3âyears in the USA is reported for adolescents ED â¦.

Welcome to the December edition of Emergency Medicine Journal, the buy amoxil with free samples final http://waitingroomn16.com/can-you-buy-amoxil-over-the-counter/ one for 2020. This has been an âinterestingâ year for Emergency Physicians and their departments, with many changes to working practices. We hope you are keeping well in these uncertain times.Vascular accessThe Editorâs buy amoxil with free samples choice this month is a randomised controlled trial (Chauvin et al) wherein patients requiring blood gas measurement were randomised to arterial or venous sampling. While the findings of less pain and increased ease for venous sampling might not be surprising, it is surprising that the clinical utility of the biochemical data (as assessed by treating physician) is equivalent.

This provides further evidence to support the move to venous blood gases for most patients.Vascular access in paediatric patients is the focus of Girotto et alsâ paper, which validates predictive buy amoxil with free samples rules (DIVA and DIVA3) for difficult venous access. Of interest are the additional factors (nurse assessment of difficulty, and dehydration status of moderate severity or more) which identified difficult access when the rule had not predicted difficulty in siting a venous cannula.Targets. Achievement and effectsThere has long been intense debate regarding the use buy amoxil with free samples of quality metrics to assess performance of Emergency Departments (cf the âGoodhart principleâ). A number of papers in this monthâs EMJ look at âtargetsâ- the effect the presence of targets can have, and the ramifications of attempts to achieve targets.Sethi et al have used a âbefore and afterâ study design to retrospectively assess the effect on Emergency Department Clinical Quality Indicators of hospital-wide interventions to improve patient flow through the hospital (the âReaderâs choiceâ for this month).

An improvement in the Emergency Department quality indicators was demonstrated when a programme buy amoxil with free samples designed to improve patient flow through the hospital was undertaken. The authors suggest that this programme may have resulted in a hospital-wide focus on the issue of âexit blockâ and this may have had a significant effect, by changing the âcultureâ of the hospital.This is complemented neatly by two further papers in this monthâs EMJ. First, Paling et al, looks at waiting times in Emergency buy amoxil with free samples Departments, using routinely collected hospital data. This paper suggests that higher bed occupancy, and higher numbers of long stay patients, increases the number of patients who remain in the Emergency Department beyond the â4âhour target (for England)â.

Second, Man et al studied the long waiting times for Emergency Medical Services (EMS), due to delayed handover from ambulance to the Emergency Department (referred to as âambulance rampingâ). The interventions within the Emergency Department buy amoxil with free samples designed to improve achievement of the â4âhour target (for Australia)â also reduced EMS wait times. As with the Sethi paper, improving patient flow has a wider reaching impact.Another paper related to this topic is a validation of the NEDOCS overcrowding score, by Hargreaves et al. This paper assesses this tool against clinician perception buy amoxil with free samples of crowding and patient safety.

The relationship between changes in overcrowding score and clinicianâs perception was assessed, and refinements to the score suggested. The differences between physician and nurse perceptions of crowding and safety are intriguing, however the âbottom lineâ may be that the search continues for the perfect scoring system for crowding.Mental health in the emergency departmentA cross-sectional study buy amoxil with free samples of Emergency Department attendances across England (Baracaia et al) is discussed in Catherine Hayhurstâs commentary. This reminds us of the high prevalence of patients presenting with mental health symptoms to our departments, and stimulates thought about how we can better meet their needs. This is buy amoxil with free samples further illustrated by the papers looking at care pathways for patients with self-harm who use ambulance services (Zayed at al), and the mental health triage tool derived using a Delphi study by Mackway-Jones.Emergency departments and buy antibioticsThis month sees three papers related to buy antibiotics.

Walton et al describe some of the key themes from an operational perspective, faced by UK Emergency Departments. These themes will be familiar to many readers, as will buy amoxil with free samples some of the suggested solutions to the challenges.Choudhary and colleagues have looked at changes in clinical presentation of cardiovascular emergencies (acute coronary syndromes, rhythm disturbances and acute heart failure) and their management during the amoxil. While the changes in patient behaviour (eg, reduced attendance) are well known, the changes in clinician behaviour (eg, increased use of thrombolysis) are not.The third paper describes changing patterns of Paediatric attendances to Emergency Departments in Canada during the amoxil (Goldman et al). The findings here will chime with us all.A simple buy amoxil with free samples communication toolA personal favourite of mine (notwithstanding a conflict of interest!.

), is a report on a quality improvement initiative by Taher and colleagues. This project looked at reducing patient anxiety and improving patient satisfaction in the ârapid assessmentâ area of a busy Emergency Department. This paper has buy amoxil with free samples much to commend it. Involvement of patients in the analysis of the issue, patient-centred metrics, and a neat description of control charts and their use.

Moreover, the simple âAEIâ communication tool described is one that I find elegant, effective and have buy amoxil with free samples adopted into my practice.Emergency mental health is part of our core business, although emergency department (ED) staff may have varying levels of comfort with this. We need to be as competent with the initial management of a patient with a mental health crisis as we are with trauma, sepsis or any other emergency. To do this, we need compassion and empathy underpinned by systems and training buy amoxil with free samples for all our staff. Our attitudes to patients in crisis are often the key to improvements in care.

If we are honest, some ED staff are fearful and worry that what they say may make a patient feel buy amoxil with free samples worse. Others may resent patients who come repeatedly in crisis. It helps to consider buy amoxil with free samples these patients just as we would patients with asthma or diabetes who may also come âin crisisâ. Our role is to help get them through that crisis, with kindness and competence.A detailed look at Hospital Episode Statistics (HES) for England 2013/2014 by Baracaia et al in EMJ show that 4.9% of all ED attendances were coded as having a primary mental health diagnosis.1 Cumulative HES data have shown an average increase in mental health attendances of 11% per year since 20132 (figure 1) far in excess of total ED attendance increase (figure 2).

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Department of Internal Medicine, amoxil antibiotic side effects National Taiwan University Hospital, Taipei, TaiwanPublication date:01 July 2021More about this publication?. The International Journal of Tuberculosis and Lung Disease (IJTLD) is for clinical research and epidemiological studies on lung health, including articles on TB, TB-HIV and respiratory diseases such as buy antibiotics, asthma, COPD, child lung health and the hazards of tobacco and air pollution. Individuals and institutes can subscribe to the IJTLD online or in print â simply email us at [email protected] for details.

The IJTLD is dedicated to understanding lung amoxil antibiotic side effects disease and to the dissemination of knowledge leading to better lung health. To allow us to share scientific research as rapidly as possible, the IJTLD is fast-tracking the publication of certain articles as preprints prior to their publication. Read fast-track articles.Editorial BoardInformation for AuthorsSubscribe to this TitleInternational Journal of Tuberculosis and Lung DiseasePublic Health ActionIngenta Connect is not responsible for the content or availability of external websitesNo AbstractNo Reference information available - sign in for access.

No Supplementary Data.No Article MediaNo amoxil antibiotic side effects MetricsDocument Type. EditorialAffiliations:1. World Health Organization South-East Asia Office, Delhi, India 2.

Research Institute of amoxil antibiotic side effects Tuberculosis/Japan Anti-TB Association, Tokyo, Japan 3. Global Infectious Diseases Consulting Ltd, London, UKPublication date:01 July 2021More about this publication?. The International Journal of Tuberculosis and Lung Disease (IJTLD) is for clinical research and epidemiological studies on lung health, including articles on TB, TB-HIV and respiratory diseases such as buy antibiotics, asthma, COPD, child lung health and the hazards of tobacco and air pollution.

Individuals and institutes can subscribe to the IJTLD online or amoxil antibiotic side effects in print â simply email us at [email protected] for details. The IJTLD is dedicated to understanding lung disease and to the dissemination of knowledge leading to better lung health. To allow us to share scientific research as rapidly as possible, the IJTLD is fast-tracking the publication of certain articles as preprints prior to their publication.

Department of Pulmonology, Kepler University Hospital, buy amoxil 500mg online Linz, Austria 2 buy amoxil with free samples. Department of Internal Medicine, National Taiwan University Hospital, Taipei, TaiwanPublication date:01 July 2021More about this publication?. The International Journal of Tuberculosis and Lung Disease (IJTLD) is for clinical research and epidemiological studies on lung health, including articles on TB, TB-HIV and respiratory diseases such as buy antibiotics, asthma, COPD, child lung health and the hazards of tobacco and air pollution. Individuals and buy amoxil with free samples institutes can subscribe to the IJTLD online or in print â simply email us at [email protected] for details. The IJTLD is dedicated to understanding lung disease and to the dissemination of knowledge leading to better lung health.

To allow us to share scientific research as rapidly as possible, the IJTLD is fast-tracking the publication of certain articles as preprints prior to their publication. Read fast-track articles.Editorial BoardInformation for AuthorsSubscribe to this TitleInternational Journal of Tuberculosis and Lung DiseasePublic Health ActionIngenta Connect is not responsible for the content or availability of external websitesNo AbstractNo Reference information available - sign in for access buy amoxil with free samples. No Supplementary Data.No Article MediaNo MetricsDocument Type. EditorialAffiliations:1. World Health Organization South-East Asia Office, Delhi, India buy amoxil with free samples 2.

Research Institute of Tuberculosis/Japan Anti-TB Association, Tokyo, Japan 3. Global Infectious Diseases Consulting Ltd, London, UKPublication date:01 July 2021More about this publication?. The International Journal of Tuberculosis and Lung Disease (IJTLD) is for clinical research and epidemiological studies on lung health, including articles on TB, TB-HIV and respiratory buy amoxil with free samples diseases such as buy antibiotics, asthma, COPD, child lung health and the hazards of tobacco and air pollution. Individuals and institutes can subscribe to the IJTLD online or in print â simply email us at [email protected] for details. The IJTLD is dedicated to understanding lung disease and to the dissemination of knowledge leading to better lung health.

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A CyberScoop report published on Friday found that the telehealth provider Doxy.me had allowed third parties amoxil capsule 250mg to Read Full Report access data about providers via its virtual waiting room. According to reporter Tonya Riley, the company appeared to be sharing the URLs of public waiting amoxil capsule 250mg rooms with Google, Facebook and the marketing vendor HubSpot.An issue, as Riley explained, is that providers choose the names of their waiting rooms â and they often include their name or the name of their practice. In other words, that information was also potentially being shared via the URL with third parties. No patient health data was amoxil capsule 250mg exposed.

"Doxy.me was notified that certain third-party URLs used on its main website were also enabled when a user enters a virtual waiting room. Data sent to those third-parties were basic browser details (version, operating system, etc.) and, in some cases, the public virtual waiting room URL (that is self-chosen by amoxil capsule 250mg each provider during the Doxy.me account registration process)," explained Doxy.me representatives in a statement to Healthcare IT News. "Once an encrypted audio/video session began, there were no embedded third-party URLs," they added. Although Riley reported that amoxil capsule 250mg the data included IP addresses and unique device identification numbers, Doxy.me said only basic browser details were collected, such as screen size and device type, "so that the audio-video communication operates optimally." WHY IT MATTERS As telehealth has grown in popularity, experts have reiterated the need to safeguard privacy and security.

In this case, user browser details were being collected for a recent marketing campaign that amoxil capsule 250mg has since ended, said Doxy.me representatives. After the CyberScoop report, Doxy.me says it removed all third-party URLs from the virtual waiting room. The company is in the process of removing all data collected from those third amoxil capsule 250mg parties. "As there is no need to continue sending browser information, we have removed the ability for these third-party websites to track the performance of our marketing campaigns," Doxy.me representatives said.

The company reiterated that it amoxil capsule 250mg neither collects nor stores patient health information. THE LARGER TREND Doxy.me has promoted its simplicity as key to its security, with founder Brandon Welch telling Healthcare IT News in June 2020 that it can rely on browser encryption rather than relying on patients to download a separate app.But its rollout faced some hurdles early in the buy antibiotics amoxil, with multifactor authentication â an important defense feature â not an initial requirement for providers. ON THE RECORD "Doxy.me regrets having those third-party URLs in the virtual waiting room entry page," said amoxil capsule 250mg company representatives. Kat Jercich amoxil capsule 250mg is senior editor of Healthcare IT News.Twitter.

@kjercichEmail. Kjercich@himss.orgHealthcare IT News amoxil capsule 250mg is a HIMSS Media publication.System1, a Los Angeles-based marketing platform company, announced this week that Epic Systems had selected its Mapquest for Business services to provide mapping, navigation and geolocation functionality. Company representatives say MapQuestâs location and mapping data will help patients find nearby or conveniently located clinicians. It will also assist home health providers amoxil capsule 250mg in getting to their destinations efficiently.

"Location data changes the way we can orchestrate and analyze care," said Epic engineering lead Drew McCombs in an email to Healthcare IT News. "Patients amoxil capsule 250mg and caregivers will be able to take advantage of mapping, search, routing, turn-by-turn directions, traffic-aware travel times, and spatial analytics across multiple applications. "For example," McCombs added, "patients will be able to find a service location closest to them, get to appointments faster and automatically alert the front-office staff when they have arrived." WHY IT MATTERS The amoxil capsule 250mg vendors say Epic will enable the option to use MapQuestâs location and mapping services across dozens of its workflows. McCombs also touted the role the partnership could play in promoting health equity."Clinicians can use location services to optimize home visits or analyze their impact in underserved areas, or investigate disease-related 'hunches,'" McCombs said.

System1 representatives amoxil capsule 250mg emphasized the importance of privacy and security alongside convenience. "Our ability to step up and commit to treating data in a HIPAA-compliant manner opens up a number of new avenues for us to bring our expertise and competitive pricing to new partners," said System1 President of Commerce and Travel, Stewart Marlborough. "We believe that the future for MapQuest is very amoxil capsule 250mg bright as consumers consider more carefully who has access to their location and other sensitive data at all times," Marlborough continued. "Location data will have the same security protections as any other element in the chart," added McCombs.THE LARGER TREND Some health IT innovators and providers have turned to location and mapping services to assist with care.

For instance, amoxil capsule 250mg in 2017, Allscripts announced that it had partnered with Zocdoc to help patients with finding doctors and scheduling appointments. The technology has also been used in a public health setting, particularly amidst the buy antibiotics crisis amoxil capsule 250mg. Google announced this past April that it would use anonymized, aggregated GPS data to help monitor the spread of the novel antibiotics. ON THE RECORD "MapQuest has long valued our partnership with Epic, and this new avenue for collaboration reflects our commitment to providing outstanding, reliable and customer-centric location and data solutions for leading healthcare systems around the world," said amoxil capsule 250mg Marlborough.

Kat Jercich is senior editor of Healthcare IT News.Twitter. @kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.It comes as a surprise to no one that healthcare's digital landscape is fragmented and siloed with numerous point solutions. UnityPoint Health, a health system based in Des Moines, Iowa, is well aware of this.THE PROBLEM"Patients want digital health tools, but they do not want 100 of them," said Matthew Warrens, managing director of innovation at UnityPoint Health.

"Providers and payers face a tidal wave of point solutions that can help meet consumer demand, but also lack a comprehensive view of a patient's data accumulated through digital sources."This makes it difficult to personalize and push meaningful interactions," he said. "Embracing digital transformation is key in order to align with patient demands and maintain market share. Digital transformation also is essential in making an impact on quality improvement and cost containment goals associated with value-based care initiatives."PROPOSALUnityPoint Health hooked up with health IT vendor b.well Connected Health. The vendor enables digital transformation through a platform that provides patients a new entry point to healthcare.

Patients can manage every aspect of their health in one centralized location. By identifying personalized health insights that help patients and providers close gaps in care, the platform supports population health and value-based care initiatives."The vendor provides a level of interoperability that is hard for health systems to create on their own," Warrens explained. "The ability to integrate with existing solutions and pull data into a comprehensive view enables real-time actionable insights, and consumer-centric engagement between health systems, providers and patients."The vendor makes it possible for patients to share their pertinent health information with providers in real time and allow anyone within their trusted circle of care to be informed as well," he added. "With the platform, UnityPoint Health will create powerful and proactive insights that drive engagement, valuable navigation and meaningful outcomes."Matthew Warrens, UnityPoint Health"It also gives patients access to all point digital solutions in one place â a preferred and manageable method compared to otherwise having to access things like virtual care, asynchronous visits and digital behavioral health through individual apps."In addition to housing multiple digital solutions in one place, b.well recommends solutions to the patient based on what is known about them, leading to a better care experience, he said.MEETING THE CHALLENGEThe patient digital health platform integrates with UnityPoint Health's electronic health record, patient portal and other existing digital solutions."Outside of this being an incredibly useful tool for patients, it will help our entire care team make patient health journeys more proactive, personal and comprehensive," Warrens noted.RESULTSUnityPoint Health still is in the early stages of deployment, so it's too early for hard results.

But the health system hopes to deliver even more personalized and convenient care to patients, leading to improved patient experience and retention."Through the convenience of the all-in-one platform, UnityPoint Health expects an increase in virtual visit utilization, reduced call center volumes and a higher percentage of closed care gaps," Warrens said.UnityPoint Health will leverage b.well to improve the efficiency of value-based care initiatives, he added."Our goal is to improve the quality of care while finding ways to maintain or lower costs, and work in ways that lead to better outcomes, value and healthier communities," he said. "With the platform, UnityPoint Health will create powerful and proactive insights that drive engagement, valuable navigation and meaningful outcomes."ADVICE FOR OTHERSBuilding a digital front end to help patients navigate a healthcare organization is not difficult if resources can be dedicated to it, Warrens advised."The heavy lift comes in creating the back end â the part that drives value for patients and the healthcare organization," he observed. "As interoperability regulations continue to change, the back end requires constant attention and development. Digital tools need stickiness to succeed â and that's achieved by providing value to patients that keeps bringing them back to the technology."When looking at implementing a similar technology, the most important thing is for organizations to stay focused on the part that is providing value â and not only the front-end step of getting patients in the door," he concluded.

"Equally important is finding a partner with expertise in interoperability that can integrate seamlessly with the electronic health record, other digital solutions and the organization's infrastructure to create meaningful insights for patients and the healthcare organization."Twitter. @SiwickiHealthITEmail the writer. Bsiwicki@himss.orgHealthcare IT News is a HIMSS Media publication..

A CyberScoop report published on Friday found that the telehealth Website provider buy amoxil with free samples Doxy.me had allowed third parties to access data about providers via its virtual waiting room. According to reporter Tonya Riley, the company appeared to be sharing the URLs of public waiting rooms with Google, Facebook and the marketing vendor HubSpot.An issue, as Riley explained, is that providers choose the names of their waiting rooms â and they often include their name or the name of their buy amoxil with free samples practice. In other words, that information was also potentially being shared via the URL with third parties.

No buy amoxil with free samples patient health data was exposed. "Doxy.me was notified that certain third-party URLs used on its main website were also enabled when a user enters a virtual waiting room. Data sent to those third-parties were basic browser details (version, operating buy amoxil with free samples system, etc.) and, in some cases, the public virtual waiting room URL (that is self-chosen by each provider during the Doxy.me account registration process)," explained Doxy.me representatives in a statement to Healthcare IT News.

"Once an encrypted audio/video session began, there were no embedded third-party URLs," they added. Although Riley reported that the data included IP addresses and buy amoxil with free samples unique device identification numbers, Doxy.me said only basic browser details were collected, such as screen size and device type, "so that the audio-video communication operates optimally." WHY IT MATTERS As telehealth has grown in popularity, experts have reiterated the need to safeguard privacy and security. In this case, user browser details were being collected for a recent marketing campaign that has since ended, said Doxy.me representatives buy amoxil with free samples.

After the CyberScoop report, Doxy.me says it removed all third-party URLs from the virtual waiting room. The company is in the process of removing all buy amoxil with free samples data collected from those third parties. "As there is no need to continue sending browser information, we have removed the ability for these third-party websites to track the performance of our marketing campaigns," Doxy.me representatives said.

The company reiterated that it neither collects nor stores patient health information buy amoxil with free samples. THE LARGER TREND Doxy.me has promoted its simplicity as key to its security, with founder Brandon Welch telling Healthcare IT News in June 2020 that it can rely on browser encryption rather than relying on patients to download a separate app.But its rollout faced some hurdles early in the buy antibiotics amoxil, with multifactor authentication â an important defense feature â not an initial requirement for providers. ON THE RECORD "Doxy.me regrets having those buy amoxil with free samples third-party URLs in the virtual waiting room entry page," said company representatives.

Kat Jercich is senior editor of Healthcare IT buy amoxil with free samples News.Twitter. @kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.System1, a Los Angeles-based marketing platform company, announced this week that Epic Systems had selected its Mapquest for Business services to provide mapping, navigation and geolocation functionality buy amoxil with free samples.

Company representatives say MapQuestâs location and mapping data will help patients find nearby or conveniently located clinicians. It will also assist buy amoxil with free samples home health providers in getting to their destinations efficiently. "Location data changes the way we can orchestrate and analyze care," said Epic engineering lead Drew McCombs in an email to Healthcare IT News.

"Patients and caregivers buy amoxil with free samples will be able to take advantage of mapping, search, routing, turn-by-turn directions, traffic-aware travel times, and spatial analytics across multiple applications. "For example," McCombs added, "patients will be able to find a service location closest to them, get to appointments faster and automatically alert the front-office staff when they have arrived." WHY IT MATTERS The vendors say Epic will enable the option to use MapQuestâs buy amoxil with free samples location and mapping services across dozens of its workflows. McCombs also touted the role the partnership could play in promoting health equity."Clinicians can use location services to optimize home visits or analyze their impact in underserved areas, or investigate disease-related 'hunches,'" McCombs said.

System1 representatives emphasized the importance of privacy and buy amoxil with free samples security alongside convenience. "Our ability to step up and commit to treating data in a HIPAA-compliant manner opens up a number of new avenues for us to bring our expertise and competitive pricing to new partners," said System1 President of Commerce and Travel, Stewart Marlborough. "We believe that the future for MapQuest is very bright as consumers consider buy amoxil with free samples more carefully who has access to their location and other sensitive data at all times," Marlborough continued.

"Location data will have the same security protections as any other element in the chart," added McCombs.THE LARGER TREND Some health IT innovators and providers have turned to location and mapping services to assist with care. For instance, buy amoxil with free samples in 2017, Allscripts announced that it had partnered with Zocdoc to help patients with finding doctors and scheduling appointments. The technology has also been used in a public health setting, particularly amidst the buy amoxil with free samples buy antibiotics crisis.

Google announced this past April that it would use anonymized, aggregated GPS data to help monitor the spread of the novel antibiotics. ON THE RECORD "MapQuest has buy amoxil with free samples long valued our partnership with Epic, and this new avenue for collaboration reflects our commitment to providing outstanding, reliable and customer-centric location and data solutions for leading healthcare systems around the world," said Marlborough. Kat Jercich is senior editor of Healthcare IT News.Twitter.

@kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.It comes as a surprise to no one that healthcare's digital landscape is fragmented and siloed with numerous point solutions. UnityPoint Health, a health system based in Des Moines, Iowa, is well aware of this.THE PROBLEM"Patients want digital health tools, but they do not want 100 of them," said Matthew Warrens, managing director of innovation at UnityPoint Health.

The vendor enables digital transformation through a platform that provides patients a new entry point to healthcare. Patients can manage every aspect of their health in one centralized location. By identifying personalized health insights that help patients and providers close gaps in care, the platform supports population health and value-based care initiatives."The vendor provides a level of interoperability that is hard for health systems to create on their own," Warrens explained.

"The ability to integrate with existing solutions and pull data into a comprehensive view enables real-time actionable insights, and consumer-centric engagement between health systems, providers and patients."The vendor makes it possible for patients to share their pertinent health information with providers in real time and allow anyone within their trusted circle of care to be informed as well," he added. "With the platform, UnityPoint Health will create powerful and proactive insights that drive engagement, valuable navigation and meaningful outcomes."Matthew Warrens, UnityPoint Health"It also gives patients access to all point digital solutions in one place â a preferred and manageable method compared to otherwise having to access things like virtual care, asynchronous visits and digital behavioral health through individual apps."In addition to housing multiple digital solutions in one place, b.well recommends solutions to the patient based on what is known about them, leading to a better care experience, he said.MEETING THE CHALLENGEThe patient digital health platform integrates with UnityPoint Health's electronic health record, patient portal and other existing digital solutions."Outside of this being an incredibly useful tool for patients, it will help our entire care team make patient health journeys more proactive, personal and comprehensive," Warrens noted.RESULTSUnityPoint Health still is in the early stages of deployment, so it's too early for hard results. But the health system hopes to deliver even more personalized and convenient care to patients, leading to improved patient experience and retention."Through the convenience of the all-in-one platform, UnityPoint Health expects an increase in virtual visit utilization, reduced call center volumes and a higher percentage of closed care gaps," Warrens said.UnityPoint Health will leverage b.well to improve the efficiency of value-based care initiatives, he added."Our goal is to improve the quality of care while finding ways to maintain or lower costs, and work in ways that lead to better outcomes, value and healthier communities," he said.

"With the platform, UnityPoint Health will create powerful and proactive insights that drive engagement, valuable navigation and meaningful outcomes."ADVICE FOR OTHERSBuilding a digital front end to help patients navigate a healthcare organization is not difficult if resources can be dedicated to it, Warrens advised."The heavy lift comes in creating the back end â the part that drives value for patients and the healthcare organization," he observed. "As interoperability regulations continue to change, the back end requires constant attention and development. Digital tools need stickiness to succeed â and that's achieved by providing value to patients that keeps bringing them back to the technology."When looking at implementing a similar technology, the most important thing is for organizations to stay focused on the part that is providing value â and not only the front-end step of getting patients in the door," he concluded.