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NIH research could low price viagra lead to new treatment strategies for stomach cancer Glucocorticoids and androgens promote a healthy stomach pit by inhibiting inflammation, left, while their absence promotes inflammation and SPEM seen in a diseased pit, right. SPEM glands are also much larger than healthy stomach glands. (Photo courtesy of Jonathan Busada, Ph.D./NIEHS) Scientists at the National Institutes of Health determined that stomach inflammation is regulated differently in male and female mice after finding that androgens, or male sex hormones, play a critical role in preventing inflammation in low price viagra the stomach.

The finding suggests that physicians could consider treating male patients with stomach inflammation differently than female patients with the same condition. The study was published in Gastroenterology.Researchers at NIHâs National Institute of Environmental Health Sciences (NIEHS) made the discovery after removing adrenal glands from low price viagra mice of both sexes. Adrenal glands produce glucocorticoids, hormones that have several functions, one of them being suppressing inflammation.

With no glucocorticoids, the female mice soon developed stomach inflammation low price viagra. The males did not. However, after removing androgens from the males, they exhibited the same stomach low price viagra inflammation seen in the females."The fact that androgens are regulating inflammation is a novel idea," said co-corresponding author John Cidlowski, Ph.D., deputy chief of the NIEHS Laboratory of Signal Transduction and head of the Molecular Endocrinology Group.

"Along with glucocorticoids, androgens offer a new way to control immune function in humans."While this study provides insight into how inflammation is being regulated in males, Cidlowski said additional research is underway to understand the process in females. The scientist handling low price viagra this phase of research is co-corresponding author Jonathan Busada, Ph.D., assistant professor at West Virginia University School of Medicine in Morgantown. When Busada started the project several years ago, he was a postdoctoral fellow working in Cidlowskiâs group.Whether inflammation is inside the stomach or elsewhere in the body, Busada said rates of chronic inflammatory and autoimmune diseases vary depending on sex.

He said eight out of 10 individuals with autoimmune disease are women, and his long-term goal is to figure out how glucocorticoids and androgens affect stomach cancer, which is induced by chronic inflammation.The current research focused on stomach glands called pits, which are embedded in the lining of the stomach.Busada said the study showed that glucocorticoids and androgens act like brake pedals on the immune system and are essential low price viagra for regulating stomach inflammation. In his analogy, glucocorticoids are the primary brakes and androgens are the emergency brakes."Females only have one layer of protection, so if you remove glucocorticoids, they develop stomach inflammation and a pre-cancerous condition in the stomach called spasmolytic polypeptide-expressing metaplasia (SPEM)," Busada said. "Males have redundancy built in, so if something cuts the glucocorticoid brake line, it is okay, because the androgens can pick low price viagra up the slack."The research also offered a possible mechanism â or biological process â behind this phenomenon.

In healthy stomach glands, the presence of glucocorticoids and androgens inhibit special immune cells called type 2 innate lymphoid cells (ILC2s). But in diseased low price viagra stomach glands, the hormones are missing. As a result, ILC2s may act like a fire alarm, directing other immune cells called macrophages to promote inflammation and damage gastric glands leading to SPEM and ultimately cancer."ILC2s are the only immune cells that contain androgen receptors and could be a potential therapeutic target," Cidlowski said.This press release describes a basic research finding.

Basic research increases our understanding of human behavior low price viagra and biology, which is foundational to advancing new and better ways to prevent, diagnose, and treat disease. Science is an unpredictable and incremental process â each research advance builds on past discoveries, often in unexpected ways. Most clinical low price viagra advances would not be possible without the knowledge of fundamental basic research.

To learn more about basic research, visit Basic Research â Digital Media Kit.Grant Numbers:ZIAES090057Fi2GM123974P20GM103434P20GM121322U54GM104942P30GM103488 Reference. Busada JT, Peterson KN, Khadka S, Xu, low price viagra X, Oakley RH, Cook DN, Cidlowski JA. 2021.

Glucocorticoids and androgens protect from gastric metaplasia by suppressing group 2 innate lymphoid cell activation. Gastroenterology. Doi.

10.1053/j.gastro.2021.04.075 [Online 7 May 2021].CORVALLIS, Ore. Â A team of Oregon State University scientists has discovered a new class of anti-cancer compounds that effectively kill liver and breast cancer cells. The findings, recently published in the journal Apoptosis, describe the discovery and characterization of compounds, designated as Select Modulators of AhR-regulated Transcription (SMAhRTs).

Edmond Francis OâDonnell III and a team of OSU researchers conducted the research in the laboratory of Siva Kolluri, a professor of cancer research at Oregon State. They also identified the aryl hydrocarbon receptor (AhR) as a new molecular target for development of cancer therapeutics. ÂOur research identified a therapeutic lead that acts through a new molecular target for treatment of certain cancers,â Kolluri said.

OâDonnell added. ÂThis is an exciting development which lays a foundation for a new class of anti-cancer therapeutics acting through the AhR.â The researchers employed two molecular screening techniques to discover potential SMAhRTs and identified a molecule â known as CGS-15943 â that activates AhR signaling and kills liver and breast cancer cells. Specifically, they studied cells from human hepatocellular carcinoma, a common type of liver cancer, and cells from triple negative breast cancer, which account for about 15% of breast cancers with the worst prognosis.

ÂWe focused on these two types of cancers because they are difficult to treat and have limited treatment options,â said Kolluri, a professor in the Department of Environmental and Molecular Toxicology in the College of Agricultural Sciences. ÂWe were encouraged by the results because they are unrelated cancers and targeting the AhR was effective in inducing death of both of these distinct cancers.â The researchers also identified the AhR-mediated pathways that contribute to the anti-cancer actions of CGS-15943. Developing cancer treatments requires a detailed understanding of how they act to induce anti-cancer effects.

The researchers determined that CGS-15943 increases the expression of a protein called Fas Ligand through the AhR and causes cancer cell death. These results provide exciting new leads for drug development, but human therapies based on these results may not be available to patients for 10 years, the researchers said. An editorial commemorating the 25th anniversary issue of the journal Apoptosis highlighted this discovery and the detailed investigation of cancer cell death promoted by CGS-15943.

In addition to Kolluri and OâDonnell, who recently completed medical school and is an orthopaedic surgery resident at UC Davis Medical Center, other authors of the paper are. Hyo Sang Jang and Nancy Kerkvliet, both from Oregon State. And Daniel Liefwalker, who formerly worked in Kolluriâs lab and is now at Oregon Health and Science University.

Kolluri is also part of Oregon Stateâs Linus Pauling Institute and The Pacific Northwest Center for Translational Environmental Health Research. Funding for the research came from the American Cancer Society, National Institute of Environmental Health Sciences, the U.S. Army Medical Research and Material Command, the Department of Defense Breast Cancer Research Program, Oregon State University and the National Cancer Institute..

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The Centers for Medicare male viagra prank & click for source. Medicaid Services (CMS) and Mathematica released a fifth and final toolkit and two case studies to highlight strategies that Accountable Care Organizations (ACOs) and End-Stage Renal Disease Seamless Care Organizations (ESCOs) use to improve quality of care, lower health care costs, and enhance beneficiariesâ experience. Mathematica completed this work as part of a contract with CMS.CMS and Mathematica conducted focus male viagra prank groups with representatives from 13 ACOs participating in the Medicare Shared Savings Program and the Next Generation ACO Model to identify strategies for providing value-based care. With insights gained through these focus groups and other CMS-sponsored events, CMSâs ACO Learning System team developed the Operational Elements Toolkit. The toolkit presents fundamental strategies that Medicare ACOs use to begin or refine operations and considers approaches to meet the following objectives.

Establishing strategic partnerships to male viagra prank strengthen or expand an organization Understanding beneficiariesâ care needs and preferences Harnessing data to improve performance and support quality reportingThe Operational Elements Toolkit is part of a broader series of resources that explores how ACOs and ESCOs provide value-based care. CMS and Mathematica added to these resources with two new case studies that highlight the following strategies. Partnering with emergency departments to improve care coordination services (Reliance Healthcare) Creating an Innovation Fund that distributes grants to local organizations to improve quality, cost, and care experience (OneCare Vermont)For more information about this toolkit and other resources highlighting ACO and ESCO initiativesâincluding previous toolkits on care transformation, provider engagement, beneficiary engagement, and care coordination, and almost two dozen case studiesâplease visit CMSâs website.Parents with young children in early care and education programs like Early Head Start may also need other kinds of support. They may need affordable male viagra prank website here higher education alternatives like community college, or job training and economic support from workforce development programs. Helping clients navigate the complexities of different programs can be difficult for service providers, especially when it comes to ensuring the right coordination between services for parents and their children.

Better program coordination may lead to greater benefits for families than individual service providers could achieve alone. Coordination requires systems change, howeverâchange achieved through active partnerships, male viagra prank engaged leadership, cooperative planning, data-informed decision making, strategic use of resources, and innovative problem solving. Mathematicaâs new digital resource on improving family outcomes through coordinated services speaks directly to this need. Our partnership framework, which shows how local partnerships tend to evolve through stages of cooperation, coordination, and collaboration, was developed to help staff document their specific approaches to coordinated services and assess the approachesâ quality and intensity necessary to have an impact on parent and child outcomes. Beyond sharing the tools and information available now, the digital resource describes upcoming initiatives that will help programs use rapid-cycle testing to pilot their approach to coordinated services and give decision makers timely and actionable evidence on possible male viagra prank ways to improve program outcomes.

We also bring to light several culturally responsive best practices and innovative methods that multigenerational programs can use to overcome access disparities among communities of color and communities experiencing poverty. For more information about Mathematicaâs coordinated services work, or to speak with one of our experts, email info@mathematica-mpr.com..

The Centers for Medicare low price viagra &. Medicaid Services (CMS) and Mathematica released a fifth and final toolkit and two case studies to highlight strategies that Accountable Care Organizations (ACOs) and End-Stage Renal Disease Seamless Care Organizations (ESCOs) use to improve quality of care, lower health care costs, and enhance beneficiariesâ experience. Mathematica completed this work as part of a contract with low price viagra CMS.CMS and Mathematica conducted focus groups with representatives from 13 ACOs participating in the Medicare Shared Savings Program and the Next Generation ACO Model to identify strategies for providing value-based care. With insights gained through these focus groups and other CMS-sponsored events, CMSâs ACO Learning System team developed the Operational Elements Toolkit.

The toolkit presents fundamental strategies that Medicare ACOs use to begin or refine operations and considers approaches to meet the following objectives. Establishing strategic partnerships to strengthen or expand an organization Understanding beneficiariesâ care needs and preferences Harnessing data to low price viagra improve performance and support quality reportingThe Operational Elements Toolkit is part of a broader series of resources that explores how ACOs and ESCOs provide value-based care. CMS and Mathematica added to these resources with two new case studies that highlight the following strategies. Partnering with emergency departments to improve care coordination services (Reliance Healthcare) Creating an Innovation Fund that distributes grants to local organizations to improve quality, cost, and care experience (OneCare Vermont)For more information about this toolkit and other resources highlighting ACO and ESCO initiativesâincluding previous toolkits on care transformation, provider engagement, beneficiary engagement, and care coordination, and almost two dozen case studiesâplease visit CMSâs website.Parents with young children in early care and education programs like Early Head Start may also need other kinds of support.

They may need affordable higher education alternatives like community college, or low price viagra job training and economic support from workforce development programs. Helping clients navigate the complexities of different programs can be difficult for service providers, especially when it comes to ensuring the right coordination between services for parents and their children. Better program coordination may lead to greater benefits for families than individual service providers could achieve alone. Coordination requires systems change, howeverâchange achieved through active partnerships, engaged leadership, cooperative planning, data-informed decision making, strategic use of resources, and innovative problem low price viagra solving.

Mathematicaâs new digital resource on improving family outcomes through coordinated services speaks directly to this need. Our partnership framework, which shows how local partnerships tend to evolve through stages of cooperation, coordination, and collaboration, was developed to help staff document their specific approaches to coordinated services and assess the approachesâ quality and intensity necessary to have an impact on parent and child outcomes. Beyond sharing the tools and information available now, the digital resource describes upcoming initiatives that will help programs use rapid-cycle testing to pilot their approach to coordinated services and give decision makers timely and actionable evidence on possible ways to improve low price viagra program outcomes. We also bring to light several culturally responsive best practices and innovative methods that multigenerational programs can use to overcome access disparities among communities of color and communities experiencing poverty.

For more information about Mathematicaâs coordinated services work, or to speak with one of our experts, email info@mathematica-mpr.com..

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Nov. 1, 2021 -- During 3 hours of oral arguments on Monday, a seeming majority of Supreme Court justices appeared receptive to blocking a Texas law that essentially outlaws abortion after 6 weeks.They seemed less certain about whether the federal government, which is also challenging the law, was within its rights to sue Texas.Senate Bill 8, which went into effect Sept. 1, allows any private citizen to file suit anywhere in the state against anyone who performs, induces, or âaids or abetsâ an abortion. If successful in court, the plaintiff is entitled to at least $10,000 and does not have to pay attorneysâ fees.

Rather, the defendants are required to pay all the legal costs.A majority of justices in September denied an emergency request to stop the law, but they agreed to quickly hear the challenges in person.At Mondayâs hearing, it appeared that a few justices who had let the law stand -- notably, conservatives Amy Coney Barrett and Brett Kavanaugh -- were now agreeing that its challengers, in particular the abortion provider Whole Womanâs Health, might have legal basis to move forward. ÂI think it's pretty likely the Court is going to do something that allows âsomeone'sâ suit against SB8 to go ahead,â tweeted Raffi Melkonian, a Houston attorney, after the hearing. ÂI don't know when they're going to do that.âThe Supreme Court usually issues its opinions months after arguments. Since these two challenges -- Whole Womanâs Health v.

Jackson and United States v. Texas -- were heard on a quicker schedule, thereâs speculation that a decision could also come quickly.âThe court clearly is in a hurry,â wrote Florida State University law professor Mary Ziegler, in a post to court-tracking site SCOTUSblog before the hearing. She said the court seems to be taking the abortion issue as seriously as most Americans, and that the justices could rule before the court hears oral arguments Dec. 3 in a Mississippi case directly challenging Roe v.

Wade.In addition, data shows abortions have been severely curtailed in Texas since the law took effect -- by as much as 50%, according to researchers at the University of Texas at Austin. They reported that 2,164 abortions were provided in September, compared with 4,313 in September 2020. ÂThe actual provisions in this law have prevented every woman in Texas from exercising a constitutional right as declared by this court,â Justice Elena Kagan said, clarifying that it was every woman who had not made a decision by 6 weeks.âUsually, in these chilling effect cases, we're kind of guessing,â she said, adding, âHere, we're not guessing. We know exactly what has happened as a result of this law.

It has chilled everybody on the ground.âJudd Edward Stone II, an attorney with the Texas Attorney Generalâs Office who argued for the state, denied Kaganâs assertion.Nineteen medical organizations, including the American Medical Association, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, American Academy of Pediatrics, and the American College of Physicians filed a friend of the court brief supporting both challenges, saying the Texas law allows legislators to interfere in the patient-doctor relationship and that it limits treatment options.Texas argued that the only way to challenge the law at the federal level would be to be sued first. Marc A. Hearron, a lawyer with the Center for Reproductive Rights who argued for Whole Womanâs Health, said that was untenable.âWhat my friends on the other side are saying is that clinics should just violate the lawâ and âsubject themselves to the risk that they will be forced to close their doors,â said Hearron.But, he said, even if providers decide to violate the law, âthey may not find physicians, nurses, uasound technicians, staff members willing to work behind the desk because this law targets all of them.âPlus, clinics run the risk that they will become permanent defendants because the law does not prohibit multiple suits, he said.Whole Womanâs Health asked the justices to stop the law by preventing the stateâs clerks from filing cases.Federal Standing Not as ClearThe U.S. Department of Justice sued Texas on Sept.

9, saying the law negated the constitutional right to an abortion.âThe Act is clearly unconstitutional under longstanding Supreme Court precedent,â Attorney General Merrick Garland said at the time. At the court, U.S. Solicitor General Elizabeth B. Prelogar called it a âbrazen attackâ on the supremacy of federal law and said that it would open the door to other states mounting similar challenges.Kagan seemed to agree.âThe entire point of this law, its purpose and its effect, is to find the chink in the armor of Ex Parte Young,â a 1908 law that âset out a basic principle of how our government is supposed to work and how people can seek review of unconstitutional state laws,â she said, decrying that âafter all these many years, some geniuses came up with a way to evade the commands of that decision.âStone waved off the concerns.

ÂNothing in this law even pretends that Texas courts could evade that because it can't,â he said.âEssentially, we would be inviting states, all 50 of them, with respect to theirun-preferred constitutional rights, to try to nullify the law of -- that this Court has laid down as to the content of those rights,â said Kagan. Kavanaugh also seemed concerned about that possibility.âIt could be free speech rights. It could be free exercise of religion rights. It could be Second Amendment rights if this position is accepted here,â he said, citing a brief submitted by the Firearms Policy Coalition that supported the Whole Womanâs Health challenge.Justice Neil Gorsuch seemed dubious that the Texas law would undercut anybodyâs right to challenge.âOften constitutional rights, of course, can only be enforced in a defensive posture, when an individual is faced either with potential liability, punitive damages, but also, of course, civil fines -- fines and even criminal sanction, including prison time,â he said.Stone argued that the U.S.

Government is ânot a proper plaintiffâ and did not have the right to sue Texas or any of its officials because none were involved in enforcing the law. If the federal government didnât like the law, it should ask Congress to fix it, said Stone.After the hearing, Texas Attorney General Ken Paxton reiterated that position. ÂThe Biden Administration does not have the power to sue a state, such as Texas, just because it disagrees with a state law that protects the unborn,â he said in a statement.A ruling on the challenges will not put an end to the litigation over SB 8.âEven if the Supreme Court does rule that the abortion provider plaintiffs are allowed to sue, it is likely that there will still need to be more litigation in a federal trial court before SB 8 is actually determined to be unconstitutional and is blocked by a court order,â wrote Ian Millhiser, a Supreme Court scholar, after the hearing.A federal judge in Austin did approve the Department of Justiceâs request for a temporary halt to the law in October, but days later, the Fifth Circuit Court of Appeals ruled it could go back into effect while the legal questions were being pondered in the courts.Nov. 1, 2021 -- From the very first page of Ross Douthatâs new memoir, The Deep Places.

A Memoir of Illness and Discovery, itâs easy to feel like youâre in the room with The New York Times columnist as he details his very painful 5-year battle with chronic Lyme disease.Douthatâs journey began in the summer of 2015 when he moved with his family from Washington, DC, to a farmhouse in Connecticut. Thatâs when he first acquired a mysterious sickness that left him wracked with pain and started his mission to figure out how to get well.Douthatâs vivid descriptions of the myriad traditional and alternative medicine treatments he tries and the doctors and patients he meets along the way is a must-read for anyone with a chronic disease, in this case Lyme, which affects 476,000 Americans every year, according to the CDC.WebMD sat down with Douthat to find out a little bit more about his journey and what he recommends to anyone with Lyme. WebMD. Your book is, at times, tough to read.

You donât shy away from sharing how much pain you were in, especially the first 2 years of your illness.Douthat. At least one reviewer has said the book is harrowing. What I tell people is that itâs harrowing, but itâs also a page turner. Itâs not a difficult read and the story ultimately offers various kinds of hope and optimism.

Thereâs also spiritual and psychological elements woven in that are helpful. In that sense, you can expect more than just a harrowing experience.WebMD. During the really tough days what helped in terms of support from friends?. Douthat.

I think people are really good at helping other people in a crisis.What you see during earthquakes and natural disasters is that thereâs this period when experts worry about a descent into lawlessness -- and yet people pull together.Theyâre aware theyâre being asked to be heroic and supportive. The challenge with chronic illness is there isnât an occasion or a discrete set of tasks to help someone. Thatâs why I stress that if youâre trying to help someone with a chronic illness, donât get discouraged. Often if you offer your presence and give that person an opportunity to talk and complain, itâs the best thing you can do.

It also helps because it takes some pressure off the people that are complained to the most.WebMD. Whatâs the weirdest remedy you tried?. Douthat. I would say the frequency machine.

Itâs alleged to use sound frequency to shake up and shatter bacteria. That to me was the weirdest followed by someone placing magnets all over the parts of my body where I had symptoms. I was aware that I had passed the fringes of medicine and was out beyond the frontier.WebMD. How are you feeling today?.

Douthat. I generally describe myself as 90-95% better. Iâm not symptom-free.Most of my symptoms are pain, which isnât true for a lot of chronically ill people who have severe fatigue. I was fortune to have pain instead.There are cycles where I will go for 4 to 6 weeks with pain as a minor annoyance and a week or 2 where it seems to come back.

At the most intense point in my illness I was taking 10 to 15 antibiotic pills a day. That was barely enough to keep the in check. Now, Iâll take an antibiotic every 6 to 8 weeks.Itâs still so strange to think that I would be taking antibiotics after 6 years of an illness.WebMD. Why was it so important for you to share your personal story?.

Douthat. For one, I write for a living and, as a writer, you want to write interesting things. This was a very interesting thing that happened to me.To the extent that itâs good to interpret any suffering as a gift, something you can make something out of, that felt appropriate.Second, there are some things I wish I had known about the complexities of chronic illness and the importance of being your own advocate. I also now recognize the importance of modern medicine (and also its limits).

Iâve figured out how to fight my way through.WebMD. Whatâs your biggest piece of advice for those with Lyme?. Douthat. Donât be passive.In this case in particular the medical communityâs impulse runs to inaction because we donât know exactly how to treat this, we donât have double-blind controlled trials and a silver bullet.I found that most doctors have a do-no-harm attitude and theyâll say âGive it 3 months, give it 6 months, see how you feel.â Sometimes that works, but for a lot of people, it doesnât.Itâs your body and itâs your life.

I now know that a really severe illness like this steals your life away.You shouldnât wait for it to come back on its own. Instead, look for doctors who can help you and talk to others about whatâs worked for them.Your path to recovery will be unique, but you need to find it for yourself. It wonât come to you.Nov. 1, 2021 -- Itâs normal to be conscious of how you look in the mirror.

Losing weight isnât just healthy, but it can also boost confidence Âin powerful ways. The CDC estimates that half of adults try to lose weight in any given year, with younger adults most likely to make the effort, followed by middle-aged adults, and older adults. Common ways of shedding extra pounds include healthy eating, exercising, and intermittent fasting. But for some, there is another path that many may consider a last resort.

Weight loss surgery. Spencer Kroll, MD, PhD, an internal medicine specialist in New Jersey, says, âPeople typically opt for weight loss surgery after failing several diet programs and sometimes medication therapy." Jeannie Boyer, a licensed dietitian in Mount Pleasant, SC, says others chose surgery to help resolve or improve diabetes, high blood pressure, and sleep apnea. ÂSome of these conditions, like diabetes and insulin treatment, make losing weight through diet and exercise very difficult, which is why surgery might be ideal,â she says. When Should You Consider Surgery?.

Kroll is a cholesterol and lipid disease expert who specializes in metabolic disease. Even though it seems that people opt for surgeries out of frustration, he says, âThis should be considered only after exhausting other options, such as significant and sustainable dietary modification.â Also, he urges people to âreview various weight loss strategies with a nutritionist, change their lifestyle, and increase physical activity to increase their metabolism and encourage weight loss.â Types of Weight Loss Surgery In a situation where you may have tried all other alternatives to losing weight, surgery might be your best bet. But which is it going to be?. A recent study conducted by the University of Michigan examines the two common types of weight loss surgery.

Sleeve gastrectomy and gastric bypass. ÂSleeve gastrectomy is an easier surgery [because] only the stomach itself is reduced in size,â Kroll says. Basically, a portion of the stomach is removed, making it smaller. ÂGastric bypass, which [involves] several surgical techniques, involves bypassing the stomach so that the esophagus is connected to the small intestine directly," Kroll says.

In other words, the stomach no longer has food entering it, but is separately attached to the intestine in order to provide digestive secretions. Sleeve Gastrectomy vs. Gastric Bypass. Which Is Safer?.

Before finding out which is safer, Ryan Howard, MD, author of the University of Michigan study, says, âItâs really important for patients to understand the risk of issues like death, complications, and hospitalization after these two procedures.â Howard, a general surgeon, tells patients that understanding what theyâre in for helps inform the decision about which type of bariatric surgery to choose. He considers the sleeve gastrectomy to be safer, though it âdoesnât confer as much weight loss.â However, just because it is safer doesnât mean you shouldnât consider other factors. ÂIf a patient has a lot of comorbidities and a bypass is going to afford a better clinical benefit, maybe that risk is worth it,â he says. A recent study that followed bariatric surgery patients for 5 years discovered that sleeve gastrectomy has a lower long-term risk of mortality, complications, and reinterventions but a higher long-term rate of surgical revision.

Complications Complications from bariatric surgery are usually rare. The American Society for Metabolic and Bariatric Surgery reports the risk of dying from weight loss surgery is less than that of gallbladder removal or hip replacement. Kroll says the 30-day mortality rate for sleeve gastrectomy patients is 0.08% while that of gastric bypass patients is 0.14%. Although these complications are rare, Kroll says there are risks of blockages due to scar tissue and of .

Outlook and Recovery âAfter having bariatric surgery, you have a new opportunity. As far as weight is concerned, you can reduce your body size,â says Susan Zilberman, a mind body eating coach in New York City. But thatâs not the end goal. If you fail to deal with what caused the excessive weight, then it will return in a matter of time.

Zilberman says the âcore emotional concerns that created the weight are still there. In order to keep the weight off, it's crucial to come to a place of self-understanding surrounding your relationship with food.â Zilberman incorporates her coaching skills when working with bariatric surgeons, nurses, and dietitians. She says that one way to heal is through mindful eating. ÂMindful eating helps you disengage from habitual, unsatisfying behaviors.

Instead of thinking about food and eating, you free up your energy and can focus on living your optimal life.â âHealing from surgery is a process. For optimum healing, it is important to follow the guidelines of your bariatric team, to think about self-care and stress reduction, and to focus on self-acceptance in the present moment.â WebMD Health News Sources Ryan Howard, MD, general surgeon, University of Michigan. Spencer Kroll, MD, PhD, internal medicine specialist, New Jersey. Jeannie Boyer, RD, LD, Mount Pleasant, SC.

Susan Zilberman, certified mind body eating coach, New York City. JAMA Surgery. ÂComparative safety of sleeve gastrectomy and gastric bypass up to 5 years after surgery in patients with severe obesity.â CDC. ÂAttempts to Lose Weight Among Adults in the United States, 2013â2016.â Â© 2021 WebMD, LLC.

All rights reserved.Nov. 1, 2021 -- A popular urban legend is that accidents and other strange things happen more often during a full moon. While the evidence doesnât bear that out, itâs possible people might sleep differently during different phases of the moon, a new study suggests.As the moonâs brightness increases daily from a new moon to a full moon, the time that it reaches its highest point in the sky also shifts from midday to near midnight. The reverse happens after a full moon, with brightness decreasing each night.

A group of researchers from Uppsala University in Sweden examined peopleâs sleeping habits during these changing phases of the moon.They analyzed sleep pattern information for 852 people from three previous, unrelated studies that assessed adult participants during one night of sleep.The researchers found that study participants slept a little less on nights when the moon was waxing, or brightening, compared with waning.The men, all from the same study conducted during 2016-2018, seemed more sensitive to the moon. They slept about 21 minutes less on waxing nights, whereas the women in the other two studies slept 12 minutes less. Men also tended to sleep less well on waxing nights and spent 14 extra minutes awake in the night after first falling asleep. Women experienced neither effect.

Although the researchers accounted for participant age and the season that they underwent their sleep tests, itâs important to note that the analysis is still based on a single night of sleep from each participant, with monitoring done at home. Also, the three studies took place at different times, from 2001 to 2004 and 2013 to 2015 for women and 2016 to 2018 for men. Much has changed during these years in terms of technology and social media use.But the findings still hint that the moon could have subtle effects on human sleep. Moonlight is a reflection of sunlight, which affects levels of melatonin, a hormone that signals nighttime and sleep time.

Previous studies have found lower melatonin and menâs testosterone levels during full moons and higher levels of the stress hormone cortisol during full moons..

It also helps because it takes some pressure off the people that are complained to the most.WebMD. Whatâs the weirdest remedy you tried?. Douthat. I would say the frequency machine.

Previous studies have found lower melatonin and menâs testosterone levels during full moons and higher levels of the stress hormone cortisol during full moons..

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Worried that a new erectile dysfunction treatment wave could overwhelm understaffed sex viagra tablets for female U.S. Hospitals, federal officials on Thursday loosened rules that call on healthcare workers to stay out of work for 10 days if they test positive.Those workers now will be allowed to come back to work after seven days if they test negative and don't have symptoms sex viagra tablets for female. Isolation time can be cut to five days, or even fewer, if there are severe staffing shortages, according to the new Centers for Disease Control and Prevention guidance."As the healthcare community prepares for an anticipated surge in patients due to omicron, CDC is updating our recommendations to reflect what we know about and exposure in the context of vaccination and booster doses," CDC Director Rochelle Walensky said in a statement."Our goal is to keep healthcare personnel and patients safe, and to address and prevent undue burden on our healthcare facilities," she added.Isolation is designed to keep infected people away from uninfected people, to prevent further spread of the viagra.CDC officials have advised that in calculating the 10-day isolation period, the first day should be the first full day after symptoms first developed or after a positive test.

If a sex viagra tablets for female person develops symptoms sometime after a positive erectile dysfunction treatment test, the quarantine period must restart, beginning one day after the symptoms develop.Chania Batten has as much reason as anybody to feel viagra fatigue.As a nurse staffing a drive-thru clinic at the only hospital in rural Roane County, West Virginia, she has spent months patiently answering questions, dispelling misinformation and reassuring the skeptical that erectile dysfunction treatment shots are the key to beating back the erectile dysfunction.Batten shudders at the thought of the viagra entering another calendar year."It is frustrating," said the mother of two young children. "We all want to get back to our lives."Soon after the first treatments were approved for use a year ago, West Virginia briefly led the nation in getting people the shots, according to the Centers for Disease Control and Prevention. But the state quickly hit a wall sex viagra tablets for female of resistance and its ranking began to slip.

It's unclear how far it fell because of discrepancies between state and federal figures, but the struggle in Roane County suggests there is plenty of room for improvement.Only about 45% of the county's population is fully vaccinated against the erectile dysfunction. Nearly one-third of the state's 55 counties are under 50%, according to the CDC.Reasons vary for sex viagra tablets for female residents' struggles to embrace the treatment. And Batten, one of the people on the front lines of a long, uphill battle to persuade the often unpersuadable, has probably heard most of them."There's still, honestly, a lot of questions about the treatment and what's in it," she said.

"There's a lot of people who are sex viagra tablets for female still scared because there's not enough information out there for them. You have all that paranoia."But now, with the omicron strain of the viagra suddenly raging through the U.S. Population, the urgency of getting people to embrace the only effective known method of mitigating the viagra has been ramped up.State hospitals continue to be stressed, warning that patient numbers are growing and sex viagra tablets for female staffing levels are shrinking.

Projections show that the number of people hospitalized for the viagra during the holiday season will approach the record of more than sex viagra tablets for female 1,000 set in September.Roane General Hospital operates the main erectile dysfunction treatment vaccination clinic for Roane County, an hour north of the state capital, Charleston. It's perched on a hillside in Spencer, population 2,000, where Bing Crosby's "White Christmas" and other holiday songs blare out of speakers throughout the town square. The 484 square mile county has 14,000 residents.In addition to her regular shift inside the hospital, there have been times when Batten was the only nurse staffing the drive-thru, sometimes with as many as a dozen vehicles in line."It can sex viagra tablets for female become overwhelming," Batten said, holding a clipboard in the chilly December air.

"But it's my job."Batten said she still likes the work, and if she had to she'd go door to door trying to convince people to get the shots. But in this part of West Virginia, not much seems to get through.Republican sex viagra tablets for female Gov. Jim Justice has tried giveaways and appearing with a dour-faced bulldog named Babydog to try to convince people to get the shots.

He has given away hundreds of thousands of state dollars through drawings to sex viagra tablets for female vaccinated residents. Last month he presented a $50,000 check to a Roane County middle school to encourage students and faculty to get vaccinated.The hospital's marketing campaign on the importance of erectile dysfunction treatment shots includes daily messages on social media, radio advertising and physician testimonials. But hospital CEO Doug Bentz said he's not sure how those messages are interpreted."In fact, I think sometimes the media hurts things because people sex viagra tablets for female are so dug in politically," Bentz said in his office recently.

"Instead of making a rational decision, they feel like they've got to stand on some sex viagra tablets for female principle. There's a lot of misinformation out there. And unfortunately I think there's sex viagra tablets for female just not the trust that we have in our government, in the media, for people to believe it."The wear and tear on the nursing profession is obvious.

In 2020 alone, 1,700 nurses opted not to renew their licenses in West Virginia.Batten, who recently recovered from a bout with the viagra herself, doesn't expect to join those who stop trying."You're still coming out here and working and doing your job, but then there's still people not wanting to come and get vaccinated," Batten said. "Or they don't see what other people are going through, especially people who have lost loved ones in the hospital."Despite the effort to spread the word, a lot of people don't even know the outdoor clinic is sex viagra tablets for female available. Batten says people ask her about the treatment when she's working inside the hospital.

Others face different obstacles, sex viagra tablets for female either because of their age or transportation challenges.But then there are the voices of resistance. Whether on moral, personal or political grounds, some people say they have no intention of being vaccinated.Roane General, a nonprofit hospital, has just 25 acute-care beds to serve the whole county. In November the hospital dedicated an expansion of its facilities that cost more than $28 million.Still, the new strain of the viagra threatens to overwhelm them."I don't think the general sex viagra tablets for female public understands what's going on inside the walls of the hospitals, inside the emergency rooms and inside the inpatient care floors," Bentz said.

"It's a different world. At Roane, we have sex viagra tablets for female limited resources. We have limited sex viagra tablets for female specialists.

Yet we are being forced to provide ICU level-type care, high acuity, with the resources that we have. It's not always ideal sex viagra tablets for female. But we have no choice."Newly infected erectile dysfunction treatment patients have two new treatment options that can be taken at home.But that convenience comes with a catch.

The pills have to be sex viagra tablets for female taken as soon as possible once symptoms appear.The challenge is getting tested, getting a prescription and starting the pills in a short window.U.S. Regulators authorized Pfizer's pill, Paxlovid, and Merck's molnupiravir last week. In high-risk patients, both were shown to reduce the chances sex viagra tablets for female of hospitalization or death from erectile dysfunction treatment, although Pfizer's was much more effective.A closer look:WHO SHOULD TAKE THESE PILLS?.

The antiviral pills aren't for everyone who gets a positive test. The pills are sex viagra tablets for female intended for those with mild or moderate erectile dysfunction treatment who are more likely to become seriously ill. That includes older people and those with other health conditions like heart disease, cancer or diabetes that make them more vulnerable.

Both pills were OK'd for adults while Paxlovid is authorized sex viagra tablets for female for children ages 12 and older.WHO SHOULDN'T TAKE THESE PILLS?. Merck's molnupiravir is not authorized for children because it might interfere with bone growth. It also sex viagra tablets for female isn't recommended for pregnant women because of the potential for birth defects.

Pfizer's pill sex viagra tablets for female isn't recommended for patients with severe kidney or liver problems. It also may not be the best option for some because it may interact with other prescriptions a patient is taking. The antiviral pills aren't authorized for people hospitalized with erectile dysfunction treatment.WHAT'S THE TREATMENT WINDOW? sex viagra tablets for female.

The pills have to be started as soon as possible, within five days of the start of symptoms. Cough, headache, fever, the loss of taste or smell and muscle and body aches are sex viagra tablets for female among the more common signs. The Centers for Disease Control and Prevention offers a website to check your symptoms.Dr.

Cameron Wolfe, an infectious disease specialist at sex viagra tablets for female Duke University Hospital, advises getting a test as soon as you have symptoms of erectile dysfunction treatment."If you wait until you have started to get breathless, you have already to a large extent missed the window where these drugs will be helpful," Wolfe said.WHERE CAN I GET THE PILLS?. You'll need a prescription first from a doctor or other authorized health worker. The U.S sex viagra tablets for female.

Government is buying the pills from Merck and Pfizer and providing them for free, but supplies will be limited initially. They'll be shipped to states where they will be available sex viagra tablets for female at drugstores, community health centers and other places. Treatment lasts five days.Some pharmacists may be able to administer a quick erectile dysfunction treatment test and sex viagra tablets for female prescribe the pills all in one visit.

They already do this in many states for flu or strep throat.WILL THE PILLS WORK FOR THE OMICRON VARIANT?. The pills are expected to be effective against omicron because they don't target the spike protein sex viagra tablets for female where most of the variant's worrisome mutations reside. The two pills work in different ways to prevent the viagra from reproducing.ARE THERE OTHER OPTIONS FOR NEW erectile dysfunction treatment PATIENTS?.

Yes, but they aren't as sex viagra tablets for female easy to use as a pill. They are given by IV or injection, typically at a hospital or clinic. Three drugs provide viagra-fighting antibodies, sex viagra tablets for female although laboratory testing suggests the two aren't effective against omicron.

British drugmaker GlaxoSmithKline's antibody drug appears to work, and officials say they are working to increase the U.S. Supply. The only antiviral drug approved in the U.S., remdesivir, is for people hospitalized with erectile dysfunction treatment..

Worried that low price viagra a new erectile dysfunction treatment wave Viagra online canada could overwhelm understaffed U.S. Hospitals, federal officials on Thursday loosened rules that call on healthcare workers to stay out low price viagra of work for 10 days if they test positive.Those workers now will be allowed to come back to work after seven days if they test negative and don't have symptoms. Isolation time can be cut to five days, or even fewer, if there are severe staffing shortages, according to the new Centers for Disease Control and Prevention guidance."As the healthcare community prepares for an anticipated surge in patients due to omicron, CDC is updating our recommendations to reflect what we know about and exposure in the context of vaccination and booster doses," CDC Director Rochelle Walensky said in a statement."Our goal is to keep healthcare personnel and patients safe, and to address and prevent undue burden on our healthcare facilities," she added.Isolation is designed to keep infected people away from uninfected people, to prevent further spread of the viagra.CDC officials have advised that in calculating the 10-day isolation period, the first day should be the first full day after symptoms first developed or after a positive test.

If a person develops symptoms sometime after a positive erectile dysfunction treatment test, the quarantine period must restart, beginning one day after the symptoms develop.Chania Batten has as much reason as anybody to feel viagra fatigue.As a nurse staffing a drive-thru clinic at the only hospital in rural Roane County, West low price viagra Virginia, she has spent months patiently answering questions, dispelling misinformation and reassuring the skeptical that erectile dysfunction treatment shots are the key to beating back the erectile dysfunction.Batten shudders at the thought of the viagra entering another calendar year."It is frustrating," said the mother of two young children. "We all want to get back to our lives."Soon after the first treatments were approved for use a year ago, West Virginia briefly led the nation in getting people the shots, according to the Centers for Disease Control and Prevention. But the state low price viagra quickly hit a wall of resistance and its ranking began to slip.

It's unclear how far it fell because of discrepancies between state and federal figures, but the struggle in Roane County suggests there is plenty of room for improvement.Only about 45% of the county's population is fully vaccinated against the erectile dysfunction. Nearly one-third of the state's 55 counties are under 50%, according low price viagra to the CDC.Reasons vary for residents' struggles to embrace the treatment. And Batten, one of the people on the front lines of a long, uphill battle to persuade the often unpersuadable, has probably heard most of them."There's still, honestly, a lot of questions about the treatment and what's in it," she said.

"There's a lot of people who are still low price viagra scared because there's not enough information out there for them. You have all that paranoia."But now, with the omicron strain of the viagra suddenly raging through the U.S. Population, the urgency of getting people to embrace the low price viagra only effective known method of mitigating the viagra has been ramped up.State hospitals continue to be stressed, warning that patient numbers are growing and staffing levels are shrinking.

Projections show that the number of people hospitalized for the viagra during the holiday season will approach the record of more than 1,000 set in September.Roane General Hospital operates the main erectile dysfunction treatment low price viagra vaccination clinic for Roane County, an hour north of the state capital, Charleston. It's perched on a hillside in Spencer, population 2,000, where Bing Crosby's "White Christmas" and other holiday songs blare out of speakers throughout the town square. The 484 square mile county has 14,000 residents.In addition to her regular shift inside the hospital, there have been times when Batten was the only nurse staffing the drive-thru, sometimes with as many as a dozen vehicles low price viagra in line."It can become overwhelming," Batten said, holding a clipboard in the chilly December air.

"But it's my job."Batten said she still likes the work, and if she had to she'd go door to door trying to convince people to get the shots. But in low price viagra this part of West Virginia, not much seems to get through.Republican Gov. Jim Justice has tried giveaways and appearing with a dour-faced bulldog named Babydog to try to convince people to get the shots.

He has given away hundreds of thousands of state low price viagra dollars through drawings to vaccinated residents. Last month he presented a $50,000 check to a Roane County middle school to encourage students and faculty to get vaccinated.The hospital's marketing campaign on the importance of erectile dysfunction treatment shots includes daily messages on social media, radio advertising and physician testimonials. But hospital CEO Doug Bentz said he's not sure how those messages are interpreted."In fact, I think sometimes the media hurts things because people are so dug in low price viagra politically," Bentz said in his office recently.

"Instead of making a rational decision, they feel like low price viagra they've got to stand on some principle. There's a lot of misinformation out there. And unfortunately I think there's just not the trust that we have in our government, in the media, for people to believe it."The wear and low price viagra tear on the nursing profession is obvious.

In 2020 alone, 1,700 nurses opted not to renew their licenses in West Virginia.Batten, who recently recovered from a bout with the viagra herself, doesn't expect to join those who stop trying."You're still coming out here and working and doing your job, but then there's still people not wanting to come and get vaccinated," Batten said. "Or they low price viagra don't see what other people are going through, especially people who have lost loved ones in the hospital."Despite the effort to spread the word, a lot of people don't even know the outdoor clinic is available. Batten says people ask her about the treatment when she's working inside the hospital.

Others face different obstacles, either because of their age low price viagra or transportation challenges.But then there are the voices of resistance. Whether on moral, personal or political grounds, some people say they have no intention of being vaccinated.Roane General, a nonprofit hospital, has just 25 acute-care beds to serve the whole county. In November low price viagra the hospital dedicated an expansion of its facilities that cost more than $28 million.Still, the new strain of the viagra threatens to overwhelm them."I don't think the general public understands what's going on inside the walls of the hospitals, inside the emergency rooms and inside the inpatient care floors," Bentz said.

"It's a different world. At Roane, low price viagra we have limited resources. We have low price viagra limited specialists.

Yet we are being forced to provide ICU level-type care, high acuity, with the resources that we have. It's not low price viagra always ideal. But we have no choice."Newly infected erectile dysfunction treatment patients have two new treatment options that can be taken at home.But that convenience comes with a catch.

The pills have to be taken as soon as possible once symptoms appear.The low price viagra challenge is getting tested, getting a prescription and starting the pills in a short window.U.S. Regulators authorized Pfizer's pill, Paxlovid, and Merck's molnupiravir last week. In high-risk patients, both were shown to reduce the chances of hospitalization or death low price viagra from erectile dysfunction treatment, although Pfizer's was much more effective.A closer look:WHO SHOULD TAKE THESE PILLS?.

The antiviral pills aren't for everyone who gets a positive test. The pills are intended for those with mild or moderate erectile dysfunction treatment who are more likely low price viagra to become seriously ill. That includes older people and those with other health conditions like heart disease, cancer or diabetes that make them more vulnerable.

Both pills were OK'd for adults while Paxlovid is authorized for children ages 12 and older.WHO SHOULDN'T TAKE THESE PILLS? low price viagra. Merck's molnupiravir is not authorized for children because it might interfere with bone growth. It also isn't recommended for pregnant women because of low price viagra the potential for birth defects.

Pfizer's pill isn't recommended for low price viagra patients with severe kidney or liver problems. It also may not be the best option for some because it may interact with other prescriptions a patient is taking. The antiviral low price viagra pills aren't authorized for people hospitalized with erectile dysfunction treatment.WHAT'S THE TREATMENT WINDOW?.

The pills have to be started as soon as possible, within five days of the start of symptoms. Cough, headache, fever, low price viagra the loss of taste or smell and muscle and body aches are among the more common signs. The Centers for Disease Control and Prevention offers a website to check your symptoms.Dr.

Cameron Wolfe, an infectious disease specialist at Duke University Hospital, advises getting a test as soon as you have symptoms of erectile dysfunction treatment."If you wait until you have started to get breathless, you have already to a large extent missed the window where these drugs will be helpful," Wolfe said.WHERE CAN I GET low price viagra THE PILLS?. You'll need a prescription first from a doctor or other authorized health worker. The U.S low price viagra.

Government is buying the pills from Merck and Pfizer and providing them for free, but supplies will be limited initially. They'll be shipped to states where they will be available low price viagra at drugstores, community health centers and other places. Treatment lasts five days.Some pharmacists may be able to administer a low price viagra quick erectile dysfunction treatment test and prescribe the pills all in one visit.

They already do this in many states for flu or strep throat.WILL THE PILLS WORK FOR THE OMICRON VARIANT?. The pills are expected to be effective against omicron because they don't target the spike low price viagra protein where most of the variant's worrisome mutations reside. The two pills work in different ways to prevent the viagra from reproducing.ARE THERE OTHER OPTIONS FOR NEW erectile dysfunction treatment PATIENTS?.

Yes, but they aren't as easy to use as low price viagra a pill. They are given by IV or injection, typically at a hospital or clinic. Three drugs provide viagra-fighting antibodies, although laboratory testing low price viagra suggests the two aren't effective against omicron.

Is viagra government funded 2020

According to economists Anne more info here Case and Angus Deaton, he said, those is viagra government funded 2020 deaths of despair in rural America are the result of changing economic and social forces that have left these areas behind. Bu the suicide numbers could be even higher, he said. ÂWe commonly assume that suicide rates are actually higher than what the reported rate is and itâs because of those overdose deaths,â he said. ÂThey will only be marked as suicide if there was a note left or some other clear indicator is viagra government funded 2020 that the overdose was intentionalâ¦ If thereâs no extra evidence to support that though, it doesnât get marked as a suicide on a death certificate.â The rise in factors contributing to suicide are highly concerning, the report said. Rates of depression tripled during the viagra, while firearm sales grew, social isolation became acute and emergency room visits for suicidal ideation , or thoughts of commiting suicide, increased.

According to the report, some researchers predict that we could see between 10,000 and 100,000 more suicides and deaths of despair over the next decade due to the viagra. During the summer of 2020, is viagra government funded 2020 the CDC reported that suicide rates were increasing. However, as the year ended, the rates seemed to drop, Mallinson said. ÂThat doesnât mean they went down everywhere,â he said. ÂThatâs the is viagra government funded 2020 national rate.

So, there may be places where they went up. Overdoses went up during erectile dysfunction treatment. Suicide-related ER visits for young female adults went up last year is viagra government funded 2020. So the erectile dysfunction treatment picture is definitely complex and itâs still emergingâ¦And weâre still seeing the emerging information about young adults. Weâre still learning how deep that impact was from closing schools and kids being home for a year.â Reports emerged during the viagra, the report said, that remote learning was taking a toll on students.

Clark County, Nevada schools re-opened after 18 students took their lives is viagra government funded 2020 between March and December 2020 â twice the rate of the previous year. Most suicide prevention starts in schools when mental health issues typically first emerge. The report found that rural school districts found it harder to continue providing services during the viagra, than their urban counterparts did. To address the rural/urban is viagra government funded 2020 suicide gap, Mallinson said, rural communities need more funding and more resources to provide prevention programs. ÂIn a privatized healthcare system, like what we have in a lot of rural counties, thereâs been a lot of healthcare consolidation,â he said.

ÂAnd consolidation has brought closures. Those closures tend is viagra government funded 2020 to be in rural areas. So, (residents in rural communities) are in a situation where if they need care, itâs even further away.â Additionally, he said, once those programs are in place, they need to be evaluated on how well they work. Many of the counties Mallinson worked with had no evaluation program in place, and those that did fell short of a proper program evaluation, having instead run research on satisfaction with the program. ââThatâs very different from real program evaluation,â is viagra government funded 2020 he said.

ÂOf course, program evaluation is hard and program evaluation can be expensive, so itâs another resource issue.â You Might Also LikeStart Preamble Start Printed Page 31404 Federal Communications Commission. Proposed rule. In this document, the Federal Communications Commission proposes to require covered text providers to support text messaging to 988, the 3-digit dialing code to is viagra government funded 2020 reach the National Suicide Prevention Lifeline. We seek comment on this proposal and related issues, such as the text message formats that covered text providers must transmit to 988 and the timeframe for implementation. Comments are due on or before July 12, 2021, and reply comments are due on or before August 10, 2021.

You may submit comments, identified by WC Docket is viagra government funded 2020 No. 18-336, by any of the following methods. Federal Communications Commission's Website. Http://apps.fcc.gov/âecfs/â. Follow the instructions for submitting comments.

Mail. Parties who choose to file by paper must file an original and one copy of each filing. Filings can be sent by commercial overnight courier, or by first-class or overnight U.S. Postal Service mail. All filings must be addressed to the Commission's Secretary, Office of the Secretary, Federal Communications Commission.

Commercial overnight mail (other than U.S. Postal Service Express Mail and Priority Mail) must be sent to 9050 Junction Drive, Annapolis Junction, MD 20701. U.S. Postal Service first-class, Express, and Priority mail must be addressed to 45 L Street NE, Washington, DC 20554. Effective March 19, 2020, and until further notice, the Commission no longer accepts any hand or messenger delivered filings.

This is a temporary measure taken to help protect the health and safety of individuals, and to mitigate the transmission of erectile dysfunction treatment. See FCC Announces Closure of FCC Headquarters Open Window and Change in Hand-Delivery Policy, Public Notice, DA 20-304 (March 19, 2020). Https://www.fcc.gov/âdocument/âfcc-closes-headquarters-open-window-and-changes-hand-delivery-policy. People with Disabilities. Contact the FCC to request reasonable accommodations (accessible format documents, sign language interpreters, CART, etc.) by email.

FCC504@fcc.gov or phone. 202-418-0530 or TTY. 202-418-0432. For detailed instructions for submitting comments and additional information on the rulemaking process, see the SUPPLEMENTARY INFORMATION section of this document. Start Further Info 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 the Commission's further notice of proposed rulemaking (FNPRM) in WC Docket No. 18-336, adopted on April 22, 2021 and released on April 23, 2021. The full text of the document is available at https://docs.fcc.gov/âpublic/âattachments/âFCC-21-47A1.pdf. To request materials in accessible formats for people with disabilities (e.g., braille, large print, electronic files, audio format, etc.) or to request reasonable accommodations (e.g., accessible format documents, sign language interpreters, CART, etc.), send an email to fcc504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at (202) 418-0530 (voice) or (202) 418-0432 (TTY).

Synopsis I. Further Notice of Proposed Rulemaking A. Text-to-988 Can Save Lives 1. In this FNPRM, we tentatively conclude that text-to-988 functionality will greatly improve consumer access to the National Suicide Prevention Lifeline (Lifeline), particularly for at-risk populations, and thereby save lives. We seek comment on this tentative conclusion, and on the benefits of text messaging as a means to facilitate access to the critical mental health resources offered by the Lifeline generally.

2. We tentatively conclude that ensuring that Americans in crisis can text 988 is likely to save lives. In the 988 notice of proposed rulemaking, the Commission observed that âAmericans, particularly younger Americans, increasingly rely on texting to communicate,â and sought comment on how to account for this fact in establishing 988 as a nationwide 3-digit code for the Lifeline. In response, numerous experts in mental health and other fields have submitted comments in this proceeding underscoring the importance of texting as a vital communications medium by which many individuals may wish to obtain crisis counseling. Further, many of these commenters noted that texting is particularly important for âmembers of vulnerable communities such as young people, low-income individuals, members of the LGBTQ community, and individuals who are deaf and hard of hearing.â We seek comment on our tentative conclusion and the assertions of these commenters regarding the importance of texting as a means to access the lifesaving resources offered by the Lifeline.

3. Just as âAmericans in crisis are in need of an easy-to-remember number to access the Lifeline's potentially life-saving resourcesâ by telephone, in our preliminary view Americans have a similarly strong need for an easy-to-remember number to reach the Lifeline by text. Because stakeholders will widely advertise 988 as the telephone number for the Lifeline, we preliminarily believe that providing text access at the same number will generate synergies that enhance the value of efforts to promote 988. Conversely, we fear that if text-to-988 is not available, Americans in crisis may be confused by efforts to promote 988 as the Lifeline's telephone number and mistakenly believe that they can reach the Lifeline by texting 988, putting lives at risk. We seek comment on this preliminary analysis.

4. As the Commission noted in the 988 Report and Order, young people are disproportionately at risk for mental health crises. They are also more likely to be most comfortable communicating via text. According to the National Alliance on Mental Illness, â[n]early 95% of teens have access to smart phones and say that texting is the primary way that they connect.â For this reason, the International Council for Helplines describes the increasing use of âchat and text services. .

. For those who are in a mental health crisis,â pointing to a recent survey indicating that â75% of millennials prefer texting over talking.â 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 As a result, Mental Health America argues, the âdata strongly support[â] the implementation of texting for providing resources to individuals experiencing suicidal ideation.â We seek comment on these views and whether adopting a text-to-988 mandate would provide particular benefits for young Americans. Are young people more inclined to seek help by text than by telephone, and if Start Printed Page 31405so, would making it easier to text the Lifeline save lives?. 5. In our preliminary view, facilitating Lifeline accessibility by text message to 988 is also likely to provide significant benefits to many other at-risk communities as well, further justifying our proposed mandate.

As the Commission explained in the 988 Report and Order, a broad range of American communities are disproportionately impacted by suicide, including Veterans, LGBTQ individuals, racial and ethnic minorities, and rural Americans. Many members of these affected communities may prefer to seek help through text messages. For example, Mental Health America reports that data they collect demonstrate that individuals âwho identify as Black or African American are more likely to report that they would like to receive a phone number they can immediately call or text for helpâ than members of any other race or ethnicity. Do commenters agree with Mental Health America that making crisis counseling services available via text message âmay mean the difference between accessing psychological support and forgoing it, especially among youth of color?. Â Is Mental Health America correct that easy access to crisis services via text may be the difference between seeking and forgoing help for such groups, and if so would use of a 3-digit dialing code for the Lifeline make a significant difference in widespread understanding that such crisis services are available?.

6. Indeed, demographic evidence regarding usage of currently available non-governmental text and chat options indicate that texting is a particularly valuable means to obtain help, not only for young people, but also for many members of low income, minority, and other communities that are disproportionately impacted by mental health crises. Several commenters in this proceeding have pointed to the successes that private non-profit services like the Trevor Project have had in providing crisis counseling to at-risk communities through text messages, offering that their experiences demonstrate the need to provide text access to 988. In addition, as one commenter to the 988 notice of proposed rulemaking argued, adding text access to 988 could allow the Lifeline and Veterans Crisis Line âto more efficiently route those in need to specialized services,â further leveraging the expertise of organizations like the Trevor Project, which provides mental health support and counseling specific to the needs of LGBTQ youth. We preliminarily agree with this assessment and believe that establishing text access to 988 will complement the important work already being done by these and other private sector organizations, and further facilitate access to the lifesaving resources offered by the Lifeline and Veterans Crisis Line.

We seek comment on these views and on the benefits of text-to-988 for at-risk groups. Are there additional at-risk communities that may benefit from texting as an option to access the Lifeline?. 7. Likewise, we preliminarily believe that our tentative conclusion is further justified because implementing text-to-988 capability will provide substantial benefits for individuals with disabilities who uniquely rely on text-based media to communicate. As the Communications Equality Advocates and others note, texting is an indispensable means of communication for individuals with disabilities.

These individuals have increasingly adopted widely available text messaging platforms such as those offered by CMRS providers and interconnected text messaging services in lieu of specialized legacy devices. Further, texting may be the only means for such individuals to contact 988 directly and efficiently. Access to telecommunications for individuals with disabilities is a longstanding Commission priority and statutory obligation, and facilitating access to 988 for deaf and hard of hearing individuals is a particularly important policy objective in light of studies finding a significantly increased risk of suicide among deaf and hard of hearing people when compared to those without hearing loss. We seek comment on these views and whether our proposal would ease access to lifesaving counseling for individuals with disabilities. Do commenters agree with the Communications Equality Advocates that the ability for individuals normally using text for the bulk of their communications, including people with disabilities, to access trained mental health professionals using text-to-988 will be of âparamount importanceâ?.

Currently, how do people with disabilities reach the Lifeline?. How would texting grant access or enhance their ability to communicate with the Lifeline?. We seek comment on whether texting would be more accessible than the options currently available, including the Lifeline's online chat portal. 8. We tentatively conclude that the potential lifesaving benefits of expanding access to suicide prevention and mental health crisis services for all Americansâand particularly the at-risk groups discussed aboveâjustifies a text-to-988 mandate, and we seek comment on this view.

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 preliminarily believe that establishing text access to 988 will further advance these important objectives by providing mental health crisis counseling through a nationally available, easy-to-remember number that Americans will also associate with the telephonic Lifeline. Do commenters agree with the Communications Equality Advocates that individuals in crisis âare likely to first use their preferred, familiar mode of communication to reach out for help?. Â We seek comment on this analysis, and on our proposed conclusion that a text-to-988 mandate is likely to offer substantial, lifesaving benefits to all Americans affected by mental health crises, particularly for many members of at-risk communities. Is a text-to-988 mandate likely to have a significant impact on the likelihood of Americans considering suicide or in a mental health crisis to contact the Lifeline?. Would mandating text-to-988 amplify the benefits of promoting 988 as the telephone number for the Lifeline?.

What are the costs or drawbacks to our proposal?. 9. In our preliminary view, the Lifeline's soft launch of a texting capability is a significant changed circumstance that supports mandating text-to-988. When the Commission adopted the 988 Report and Order, the Lifeline was not capable of receiving or responding to text messages. The Commission, stating that it has no authority to require the Lifeline to develop texting capability, deferred âconsideration of mandating text-to-988 at this time so that we could revisit the issue promptly should the Lifeline develop integrated texting.â Now, the Lifeline is capable of responding to texts sent to the Lifeline.

The Lifeline's ability to respond to texts significantly strengthens the case for imposing a text-to-988 mandate on providers. We seek comment on this evaluation. 10. We preliminarily expect many of the same lifesaving benefits from texting to 911 to accrue from texting to 988. In its comments in support of adopting a text-to-988 requirement, CTIA notes that text-to-911 functionality âhas saved countless lives and enabled public safety to keep pace with the modern Start Printed Page 31406communications preferences of consumers.â Given the parallels between the Commission's efforts to promote text access to 911 and our proposals in this FNPRM, are there lessons learned in the context of establishing text-to-911 capability that would be instructive here?.

CTIA states that there are âsignificant technical and policy differences between the national 9-8-8 service that will be administered by the Lifeline and the local 9-1-1 services that are administered by thousands of PSAPs.â For example, unlike calls to 911, which carriers route to one of thousands of local PSAPs across the country based on the caller's geographic location, all calls to 988 are routed to a central toll free number, and are then directed within the Lifeline network to a local crisis center. How might these or other differences between the 911 and 988 networks affect our proposal to adopt a text-to-988 requirement?. B. Proposed Implementation of Text-to-988 1. Scope of Text-to-988 Requirement 11.

Text Formats. We seek comment on an appropriate scope of text messages that covered text providers must transmit to 988. At present, the Lifeline is capable of receiving text messages sent to the existing 10-digit number in âshort message serviceâ (SMS) format. The Commission's Truth in Caller ID rules define the term `short message service' or SMS as âa wireless messaging service that enables users to send and receive short text messages, typically 160 characters or fewer, to or from mobile phones and can support a host of applications.â We recognize, however, that our federal partners may incorporate additional capabilities for receiving and responding to text messages in the future. We seek to adopt a forward-looking, flexible scope that can expand with the capabilities of the Lifeline without unnecessarily burdening covered text providers by requiring support of formats that the Lifeline is not yet capable of receiving.

To that end, we propose (1) establishing a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support. And (2) directing 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. We seek comment on this proposal in detail below. 12. First, we propose to define the outer bound of text messages that covered text providers may be required to transmit to 988 based on the definition of âtext messageâ that Congress enacted in 2018 in the context of Truth in Caller ID requirements.

The term âtext messageâ (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 or N11 service code. (ii) includes a [SMS] message and a multimedia message service (commonly referred to as `MMS') message. And (iii) does not includeâ(I) a real-time, two-way voice or video communication. Or (II) a message sent over an IP-enabled messaging service to another user of the same messaging service, except a message described in clause (ii). The Commission's Truth in Caller ID rules define MMS as âa wireless messaging service that is an extension of the SMS protocol and can deliver a variety of media, and enables users to send pictures, videos, and attachments over wireless messaging channels.â We seek comment on this proposed scope.

We believe this definition has several advantagesâit incorporates multimedia messages. It is not limited to specific technologies. And it reflects a recent determination by Congress, albeit in a different policy context. For the purpose of our text-to-988 rules, we propose adding âor 988â to the phrase â10-digit telephone number or N11 service codeâ so that text messages from the Lifeline identified by the 3-digit code 988 are included within the scope of covered text providers' obligations, and we seek comment on this proposal. We seek comment on whether using the Truth in Caller ID definition appropriately sets an outer bound that would achieve our goals of adopting a forward-looking, flexible scope that can expand with the capabilities of the Lifeline without unnecessarily burdening covered text providers.

13. We note that the Truth in Caller ID statutory definition of âtext messageâ excludes âreal-time, two-way voice or video communications,â as well as âmessages sent over. . . IP-enabled messaging services to another user of the same messaging service.â If we adopt the Truth in Caller ID definition, we seek comment on how we should interpret each of these two exclusions here.

Is there any reason to adopt a different interpretation of the relevant exclusions in this context compared to the Truth in Caller ID context?. Â Would adopting the Truth in Caller ID definition of âtext message,â with the exclusions specified above, prevent us from possibly adding ânext-generationâ text messages to our requirements in the future?. 14. We also seek comment on alternative outer scopes of required texts. For instance, should we adopt the scope of our text-to-911 rules, which require providers to route âa message, consisting of text characters, sent to the short code `911' and intended to be delivered to a PSAP by a covered text provider, regardless of the text messaging platform usedâ?.

In the Text-to-911 Second Report and Order, the Commission identified SMS and MMS messages as examples of text messages included within the scope of this proposed rule. We seek comment on whether the Truth in Caller ID definition, the text-to-911 definition, or another definition offers the best model here. We note that the Truth in Caller ID model is newer than the text-to-911 definition, originates with Congress rather than the Commission, and unlike the text-to-911 definition explicitly includes images, sounds, and other non-textual information. On the other hand, the Commission developed the text-to-911 definition in a more analogous policy context than the Truth in Caller ID definition. Do these or other considerations suggest that one or the other model is superior?.

15. Should we ensure that any definition we adopt encompasses next-generation forms of text messaging, such as MMS, Rich Communications Services (RCS), and/or real-time text (RTT), and what modificationsâif anyâwould we need to make to the definitions we are considering to ensure that such forms are within our proposed scope?. RCS has been described as a âsuccessor protocolâ to SMS, or as ânext-generationâ SMS. What are the fundamental differences between SMS, MMS, and RCS?. How would the costs to implement SMS, MMS, and RCS differ?.

The Commission has previously concluded that âmessages sent over other IP-enabled messaging services that are not SMS or MMSâsuch as [RCS]âare excluded fromâ the Truth in Caller ID definition of text message âto the extent such messages are sent to other users of the same messaging service.â Would it be necessary to modify the Truth in Caller ID definition for our purposes to ensure that it includes RCS or other next-generation services?. 16. We also seek comment on whether we should ensure that our proposed outer bound definition of text message encompasses RTT. Telecommunications for the Deaf and Hard of Hearing, Inc., et al. Have urged us to mandate the ability to reach 988 by RTT, noting that the Commission âhas acknowledged the benefits of RTT in crisis situations such as `allow[ing] for interruption and reduc[ing] the risk of crossed messages Start Printed Page 31407because the.

. . Call taker is able to read the caller's message as it is being typed, rather than waiting until the caller presses the `send' key.â We seek comment on this assertion and other potential benefits and drawbacks of RTT to 988. We note that pursuant to the 2016 RTT Order, all wireless service providers are permitted to support RTT on their IP networks for purposes of 911 compliance (and for purposes of complying with the general accessibility requirements of Parts 6, 7, and 14 of the Commission's rules) as an alternative to supporting TTY communications over IP. In light of the deployment of such RTT capabilities in wireless IP networks, are there any impediments to wireless service providers routing RTT texts to the 988 number, in the event that Lifeline chooses to support RTT?.

Do newer text messaging protocols like RTT and RCS represent a significant portion of the text messaging ecosystem, or are they likely to in the near future?. Are consumers likely to expect the ability to use these kinds of platforms to send text messages to 988?. Do these texting solutions make texting more accessible for individuals with disabilities?. Are there other reasons to include, or exclude, these types of applications from our definition?. Are there any text message formats that we should specifically exclude from the definition we adopt?.

For example, in crafting the text-to-911 rules, the Commission chose to exclude from its requirements a variety of services, including ârelay service. . . , mobile satellite service (MSS), and in-flight text messaging services,â as well as âtext messages that originate from Wi-Fi only locations or that are transmitted from devices that cannot access the CMRS network.â Should we adopt any similar exclusions here?. 17.

Second, we seek comment on how to structure our delegation to the Bureau to ensure that covered text providers support formats within the scope of the definition we adopt that the Lifeline can receive. We propose, as an initial matter, requiring covered text providers to support transmission of SMS messages to 988, since that is what the Lifeline can presently receive. We further propose directing the Bureau, after consultation with our federal partners at SAMHSA and the VA, to issue a Public Notice no less frequently than annually proposing and seeking comment on requiring covered text providers to transmit any new message formats to 988 that the Lifeline can receive and that are within the scope of the definition we adopt. If the Bureau proposes requiring implementation of a new message format, we further propose directing the Bureau, after notice and comment, to issue a second Public Notice, requiring covered text providers to transmit the new message format to 988 by a fixed deadline that we specify unless the record demonstrates that implementation is not technically feasible. We seek comment on this proposal.

Does it appropriately balance the need for expedient implementation with avoiding unduly burdening covered text providers with implementing formats that the Lifeline cannot receive?. Should we require the Bureau to issue a Public Notice more or less often than annually?. Or is there another mechanism, such as one similar to the Commission's Text-to-911 PSAP registry, whereby PSAPs issue a valid request for texting service from covered text providers, that we should consider?. Is technical feasibility an appropriate standard for exclusion, or do commenters recommend a different standard?. Should we have a standard for exclusion by the Bureau at all?.

If we do not have a standard for excluding certain technologies, is notice and comment necessary?. What is an appropriate implementation deadline for us to specify after the Bureau issues its Public Notice requiring implementation?. For instance, would six months be sufficient?. Should we instead allow the Bureau flexibility to set an appropriate deadline?. Should we provide any further direction to the Bureau regarding the evaluation we propose to require?.

18. We also seek comment on structuring the scope of covered text messages differently. For instance, should we simply adopt a definition of âtext messageâ and require covered text providers to support all such formats, regardless of whether the Lifeline can support that format presently?. Should we adopt a narrower definition of âtext messageâ that conforms to what the Lifeline can support at present?. While we appreciate the simplicity of either of these approaches compared to our proposal, how would commenters address our concern that the former is unnecessarily burdensome, and the latter is not adequately future-proofed?.

19. Covered Text Providers. We propose to apply our text-to-988 requirement to âcovered text providersâ as that term is defined in the text-to-911 rules, to âinclude[â] 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.â We note that the term âcovered text providerâ used in this notice of proposed rulemaking differs from the term âcovered providersâ used in the rules the Commission adopted in the 988 Order, which refers to all telecommunications carriers, interconnected VoIP providers, and one-way VoIP providers. We seek comment on this proposal, and on any alternative approaches to the scope of entities that must establish text-to-988 transmission capability.

For example, if we can apply the definition of âtext messageâ in the Truth in Caller ID rules to texting to 988, should we apply our text-to-988 rules to providers of âtext messaging services,â as defined in section 227 of the Act and our Truth in Caller ID rules?. In that context, we define âtext messaging serviceâ as âa service that enables the transmission or receipt of a text message.â Is the Truth in Caller ID model preferable, for instance because it may incorporate a broader range of providers that support text messaging service, or is our proposal preferable, for instance because it is more specific?. We also seek comment on other possible models and scopes of covered providers. Would using âCMRS providersâ exclude services over certain spectrum bands or non-switched wireless services that transmit text messages to 988, and should we instead include âwireless carriers,â or a different term, in our definition of âcovered text providers?. Â 20.

Interconnected Text Messaging Services. In adopting the text-to-911 rules, the Commission observed that there are a variety of widely available text messaging services and platforms with different technological capabilities, including SMS, MMS, and âover-the-topâ (OTT) applications delivered over internet protocol (IP)-based mobile data networks. As the Commission explained in the Text-to-911 Second Report and Order, âSMS requires use of an underlying carrier's SMS Center (SMSC) to send and receive messages from other usersâ while â[MMS]-based messaging makes use of the SMSC but also involves the use of different functional elements to enable transport of the message over IP networks.â A third category, OTT applications, may be offered by CMRS providers or third parties and allow consumers âto send text messages using SMS, MMS or directly via IP over a data connection to dedicated messaging servers and gateways.â These OTT services, which are often downloaded through mobile app stores, are increasingly popular with consumers and may be interconnected with the publicly Start Printed Page 31408switched telephone network (PSTN) or not. For purposes of the Commission's text-to-911 rules, interconnected text messaging applications enable consumers to âsend text messages to all or substantially all text-capable U.S. Telephone numbers and receive text messages from the same,â while non-interconnected applications âonly support communication with a defined set of users of compatible applications but do not support general communication with text-capable telephone numbers.â The Commission's text-to-911 rules include interconnected text messaging services but exclude non-interconnected applications because they do not provide the ability to communicate with text-capable U.S.

Telephone numbers. 21. As in the text-to-911 rules, we propose to apply our text-to-988 requirements to interconnected text messaging services, thereby excluding non-interconnected applications from the requirements. We seek comment on this approach. This approach is also analogous to the Commission's decision in the 988 Report and Order to apply to âproviders that access the [PSTN] on an interconnected basis to reach all Americansâ and any âproviders that access the [PSTN] on an interconnected basis to reach all Americans.â We note that the Commission's Truth in Caller ID rules provide an exemption for messages âsent over an IP-enabled messaging service to another user of the same messaging service, except [for an SMS or MMS message],â which similarly operates to exclude non-interconnected text messaging services.

Since the services provided by the Lifeline require two-way communication and, by definition, non-interconnected text messaging applications cannot support two-way texting with âall or substantially all text-capable U.S. Telephone numbers,â we believe it is unlikely that these services would be technically capable of supporting text-to-988 functionality. We seek comment on this view. Are there any tools available to the Commission to mitigate the potential for consumer confusion regarding the availability of text-to-988 across different text messaging platforms and technologies, particularly with respect to non-interconnected text messaging applications?. 2.

Routing Texts to 988 22. We propose to require that covered text providers route covered 988 text messages to the Lifeline's current 10-digit number, 1-800-273-8255 (TALK), and we seek comment on this proposal. This proposal is consistent with the Commission's decision for routing calls to 988 in the 988 Report and Order. In the 988 Report and Order, the Commission required âthat service providers transmit all calls initiated by an end user dialing 988 to the current toll free access number for the Lifeline,â finding that a centralized routing solution will allow for faster implementation of the 988 3-digit dialing code, lower costs to maintain 988 routing, and provide continued easy access to Lifeline by callers with disabilities. We preliminarily believe that there are similar benefits to routing texts to 988 to a single, centralized number and seek comment on this view.

23. There is support in the record thus far for routing to the Lifeline. CTIA supports directing texts sent to 988 to the Lifeline as a âcentral point for receiving such communications,â consistent with the Commission's mandate for routing 988 voice calls. Vibrant Emotional Health, the administrator of the Lifeline, argues in support of text-to-988 functionality integrated into the current Lifeline structure for routing voice and chat services, with oversight squarely within the role of the Lifeline's administrator. We seek comment on these assessments.

24. We anticipate that requiring covered text providers to route to a single destination provides SAMHSA and the VA with flexibility to develop their own routing solutions among the local crisis centers, including adding new crisis centers in the future, as compared to requiring covered text providers to implement additional updates or routing changes as more centers are added. Callers to 1-800-273-8255 (TALK) can reach the Veterans Crisis Line by pressing option 1 to connect with one of three linked call centers in New York, Georgia, or Kansas. For other calls, calls to the Lifeline from anywhere in the United States are routed to the closest certified local crisis center according to the caller's area code or, should the closest center be overwhelmed by call volume, experience a disruption of service, or if the call is placed from part of a state not covered by Lifeline's network, the system automatically routes calls to a backup center. We seek comment on this preliminary analysis.

Do the current obligations to route voice calls to 988 to the Lifeline 10-digit number offer any opportunities for streamlining implementation or reducing costs associated with routing texts to 988 to the same number?. 25. In the alternative, we seek comment on whether instead to follow a model more comparable to the text-to-911 architecture, whereby covered text providers route directly to a PSAP by requiring routing directly to a Lifeline local crisis center or to a Veterans Crisis Line crisis center. We anticipate that this approach would be significantly more costly than centralized routing and seek comment on this preliminary view. Is it easier to route texts to a single number than to individual crisis centers?.

As the Veterans Crisis Line is not currently set up for geographic distribution, would this architecture be appropriate for messages by Veterans or Service Members?. Are covered text providers able to leverage existing text-to-911 systems to reduce costs if required to route texts to 988 directly to local crisis centers?. In the 988 Report and Order, the Commission recognized that some commenters expressed there may be benefits to routing voice calls to individual crisis centers, such as familiarity with a caller's area and potentially easier coordination with local emergency services, but ultimately concluded that the advantages associated with routing to a single number outweighed the benefits of localized routing. Does that rationale apply here?. Are there benefits to routing texts to the individual crisis centers that are unique to text messages, such as providing localized support to the public in the vicinity of the crisis center?.

What are the costs or drawbacks to covered text providers to route texts to the Lifeline 10-digit number versus the local crisis centers?. Which approach will lead to speedier implementation, and how should that impact our analysis?. Is there another alternative approach, other than centralized routing or routing by crisis center, that we should consider?. 26. Currently, Veterans and Service Members may dial the Lifeline to reach the Veterans Crisis Line via voice call, but the Lifeline texting service and the VA's short code texting service require contacting separate numbers.

How should we account for this distinction in evaluating what rules to adopt to ensure that Veterans, Service Members, and their families are able to reach the Veterans Crisis Line directly and promptly?. We seek comment on whether and how we can act to facilitate integration of the Veterans Crisis Line's separate short code-based texting service into text-to-988 routing. Are there specific actions that the Commission should take to allow users to text 988 and reach both the Lifeline and Veteran-specific assistance?. For instance, should we require covered text providers to provide an automated inquiry as to whether the texter is a Veteran or Service Member and route Start Printed Page 31409the text to either the existing Lifeline number or the existing short code for Veterans depending on the response?. Alternatively, would it be feasible to immediately prompt individuals texting to 988 to reply with the number â1â or âVetâ to be routed to the Veterans Crisis Line, similar to the experience for voice callers?.

Are other prompts preferable?. We seek comment on possible solutions to ensure that texts are routed to the proper counseling services via the Lifeline or the Veterans Crisis Line, including input on technical feasibility, ways to minimize consumer confusion, and implementation costs. Should other text or chat services be integrated into 988 text routing, and if so, how?. 27. We seek comment on whether we should require covered text providers to enable text-to-988 messages to include location information.

As required by the National Suicide Hotline Designation Act of 2020, the Bureau will report to Congress on the costs and feasibility of providing location information with 988 calls on April 17, 2021. In our preliminary view, given that we have not adopted a location mandate in the context of calls to 988, we believe it would be premature to adopt a mandate here, and we seek comment on this view. Does someone who sends a text message to 988 expect that their location will be transmitted to the Lifeline?. If consumers generally are aware that calls and texts to 911 include their location, would the same expectation apply to texts to 988?. Would including location information deter at-risk individuals from texting to 988?.

We seek comment on any complications inherent in this plan and on ways for covered text providers to work with SAMHSA and the VA to limit misrouting of texts. 3. Implementation Timeframe for Text-to-988 28. Uniform Nationwide Deadline. We seek comment on an appropriate implementation timeframe for requiring covered text providers to support texting to 988 on a nationwide basis.

We preliminarily propose adopting a uniform nationwide deadline for implementation for all covered text providers and for all covered 988 text messages, as determined by the Bureau. In the 988 Report and Order, the Commission determined that the ârollout of 988 will be most effective if [it] set a single implementation deadline so that stakeholders can clearly and consistently communicate to the American public when 988 will be universally available.â We preliminarily believe that the same holds true here, and we seek comment on this view. Are there other benefits to a uniform nationwide implementation deadline?. What drawbacks, if any, exist?. 29.

Although we propose adopting a uniform nationwide deadline, we seek comment on whether we should adopt any extensions or exemptions for certain classes of providers or categories of text messages. Should we adopt any extensions or exemptions for smaller, rural, or regional covered text providers?. If so, under what circumstances would such exemptions be appropriate?. Are there unique technical considerations that necessitate different implementation timelines for certain covered text providers?. If so, what are they and why?.

Are there any other considerations, such as any existing contractual obligations between our federal partners and other entities, that we should take into account in setting a deadline or deadlines?. 30. Appropriate Deadline. We observe that CTIA and other commenters have previously argued that the Commission should not mandate text-to-988 before the Lifeline is capable of receiving and responding to texts, in part because the Lifeline's readiness to receive and respond to text messages is crucial to implementing text-to-988 successfully. We seek comment on this assertion.

We also seek comment on CTIA's proposal to require covered text providers to âdeliver text-to-988 to the Lifeline by July 16, 2022, or six months after the Lifeline demonstrates its readiness to accept text messages, whichever is later.â Is the Lifeline's pilot program sufficient to demonstrate that it is ready to accept text messages?. If not, how should we determine that the Lifeline has demonstrated readiness to accept text messages, both from a technical and operational standpoint?. How should we take into account the capabilities of the Veterans Crisis Line in establishing a deadline?. Understanding that the Lifeline and Veterans Crisis Line successfully accepting and responding to text messages to 988 will require coordination between several stakeholders, we emphasize that the Commission will continue to coordinate closely with our federal partners, SAMHSA and the VA, in their efforts to enable crisis centers to respond to text messages to 988 and establish a reasonable implementation timeframe for text-to-988. We reiterate that the Commission does not wish to determine for SAMHSA how it allocates the Lifeline's resources, nor do we have the authority to require the Lifeline and its crisis centers to be capable of receiving and responding to text messages to 988.

31. We seek comment on whether the Commission should require all covered text providers to support text-to-988 by July 16, 2022, the same implementation deadline for telecommunications carriers, interconnected VoIP providers, and one-way VoIP providers to support voice calls to 988. Is this technically, economically and operationally feasible?. Are there benefits to requiring a uniform implementation timeline for all voice and text communications to 988?. We observe that some covered text providers have already implemented voice calling to 988.

For those providers, will requiring covered text providers to implement text-to-988 on the same timeline as voice calling to 988 create any efficiencies, such as reducing fixed costs?. Is there an expectation that once 988 is deployed nationwide for voice communications that texting to 988 will be similarly available?. Will a uniform implementation deadline discourage covered text providers from potentially supporting text to 988 before July 16, 2022?. Are there other potential benefits or drawbacks to uniform implementation deadlines for providers supporting voice calling and texting to 988?. 32.

Alternatively, we seek comment on whether we should separate the timeline for implementing text-to-988 from the implementation timeline for voice-to-988. Is a phased-in approach preferable?. Would it be beneficial to consider balance of telecommunications activation needs and organizational response needs by SAMHSA and the VA?. Would it be less burdensome on providers working to implement 988 for voice calls in accordance with the 988 Report and Order?. Would a phased-in implementation timeline create consumer confusion regarding the availability of texting to 988?.

If phased-in implementation deadlines would create consumer confusion, would requiring certain covered text providers to implement text-to-988 more quickly minimize consumer confusion?. For example, if a covered text provider has already implemented voice calling to 988 and is advertising the availability of 988 to its customers, should the provider be required to implement text-to-988 before other covered text providers?. Are there other risks associated with a phased-in approach to an implementation timeline for voice and text communications to 988 as compared to uniform implementation timeline?. What, if any, phased-in deadlines should the Commission consider?. 33.

We also seek comment on whether we should we adopt the same timeline for all covered text providers, regardless of the text messaging technology they use. Are there other preparedness concerns that we should take into Start Printed Page 31410consideration when determining an implementation timeframe?. 4. Technical Considerations 34. We seek comment on the specific technical considerations for covered text providers and equipment and software vendorsâincluding those providers who are rural or small businessesânecessary to implement text-to-988.

We propose to allow covered text providers to use any reliable method or methods (e.g., mobile-switched, IP-based) to support text routing and transmission to 988, similar to text-to-911 implementation. We seek comment on this proposal. 35. Network Upgrades. We seek comment on possible upgrades covered text providers would have to make to their networks to support text-to-988 capability.

Since we propose to allow covered text providers to use any reliable method or methods to support text routing and delivery to 988, are any necessary network hardware or software upgrades small in scope?. What specific components would require upgrading?. Can the current solutions to enable text-to-911 capability be leveraged to support text-to-988, or are the implementation options for covered text providers to support text-to-988 significantly different?. CTIA notes âthere are significant technical and policy differences between national 9-8-8 service that will be administered by the Lifeline and the local 9-1-1 services that are administered by thousands of PSAPs.â We seek comment on CTIA's view, especially with regard to any âsignificantâ technical differences. Conversely, do commenters agree with Communications Equality Advocates that the costs to covered text providers for implementation of text-to-988 should be substantially lower than those associated with implementing text-to-911?.

We seek further comment on the potential integration of text-to-988 solutions with existing systems, as well as other network considerations specific to covered text providers to support text-to-988. 36. We also seek comment on whether there are unique network considerations for different text messaging service technologies within the proposed outer bound scope of text-to-988 service that impact implementation. CTIA comments that its member companies are âoptimistic about the technical feasibility of supporting text-to-988,â provided that implementation is consistent with existing capabilities of native SMS messaging. Do commenters agree?.

Are there fewer network upgrades necessary to support SMS-only texts to 988?. What specific network upgrades would be required should we obligate covered text providers to support other text messaging formats, such as MMS, RTT, or RCS?. Given that the Commission has recognized MMS as âan extension of the SMS protocol,â would support for MMS messaging be comparably feasible to support for SMS?. How does the evolution of texting services to new or future formats affect network upgrade options and implementation, and how should our rules account for such evolution?. Would requiring support for certain text messaging formats be more feasible for covered text providers to implement than others?.

37. We specifically seek comment on the technical implementation capability and network upgrades necessary for interconnected text messaging service providers. Similar to the Commission's conclusion in the Text-to-911 proceeding, we anticipate that many interconnected text messaging service providers may choose to use a CMRS network-based solution to deliver texts to 988 and seek comment on this expectation. Have there been developments in text-to-911 delivery by interconnected text messaging service providers that such providers can use in text-to-988 implementation?. In the text-to-911 context, the Commission's rules state.

To the extent that CMRS providers offer Short Message Service (SMS), they shall allow access by any other covered text provider to the capabilities necessary for transmission of 911 text messages originating on such other covered text providers' application services. Covered text providers using the CMRS network to deliver 911 text messages must clearly inform consumers that, absent an SMS plan with the consumer's underlying CMRS provider, the covered text provider may be unable to deliver 911 text messages. CMRS providers may migrate to other technologies and need not retain SMS networks solely for other covered text providers' 911 use, but must notify the affected covered text providers not less than 90 days before the migration is to occur. We seek comment on adopting this or a comparable requirement here. We recognize that text-to-911 network integration is necessary to facilitate a CMRS network-based solution, and we seek comment on whether the same integration is necessary for transmission of text-to-988 communications by other covered text providers using that solution.

We seek comment on the relationship between CMRS providers and interconnected text messaging service providers to maintain support and capability for text-to-988 service based on the technical solutions available. We emphasize that, as in the text-to-911 proceeding, even if we were to adopt a rule comparable to the text-to-911 rule above, we do not intend to establish an open-ended obligation for CMRS providers to maintain underlying SMS network support merely for the use of other providers. Further, similar to the Commission's position in the Text-to-911 Second Report and Order, if we adopt a rule comparable to the text-to-911 rule above, we propose concluding 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. We seek comment on this proposal. Finally, as in the text-to-911 context, if we adopt a rule comparable to the text-to-911 rule above, we propose requiring 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 seek comment on this proposal. 38. We also seek comment on specific technical considerations for covered text providers that are rural or regional providers, or small businesses. Are there unique impediments or challenges to implementation that these types of providers face that warrant further consideration?. 39.

Equipment Upgrades. We seek comment on possible equipment or software upgrades required for covered text providers to implement text-to-988. What challenges will equipment (e.g., handsets, network infrastructure) and software vendors face with respect to the implementation and deployment of text-to-988?. For example, are upgrades required for operating systems, firmware, or other software on mobile devices to support text-to-988 capability?. Are there upgrades necessary by vendors that are beyond the covered text providers' control that require additional coordination?.

Will new standards need to be defined to ensure interoperability?. 40. In the Text-to-911 proceeding, the Commission clarified that legacy devices that are incapable of sending texts via 3-digit codes are not subject to the text-to-911 requirements, provided the software for these devices cannot be upgraded over the air to allow text-to-911. If the device's text messaging software can be upgraded over the air to support a text to 911, however, then the Commission required the covered text provider to make the necessary software upgrade available. Should we include a Start Printed Page 31411similar exemption for legacy devices under any text-to-988 requirements we may adopt?.

Have circumstances changed in the past seven years such that we should adopt a different approach here?. 5. Cost Recovery 41. Consistent with the Commission's decision in the 988 Report and Order, we propose to require that all covered text providers bear their own costs to implement text-to-988 capability to the Lifeline 10-digit number. As with call routing to 988, we do not anticipate any shared industry costs are necessary to implement text-to-988, in contrast to previous non-988 numbering proceedings where the Commission established a cost recovery mechanism.

As proposed, costs to support text-to-988 would be borne by each provider, specific to the solutions each has adopted to route texts to 988 ultimately to the Lifeline's current toll free access number, presently 1-800-273-8255 (TALK). We seek comment on this proposal. 42. We believe this approach promotes efficiency in implementation and avoids unnecessary administrative costs. Section 251(e)(2) of the Act states 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 basis.â The Commission typically applies cost recovery mechanisms in situations involving some type of numbering administration arrangement, such as when the Commission hires a third party to develop a database for industry use, to ensure that the statutory cost neutrality requirements are met.

Here, as with implementation of voice calls to 988, circumstances do not require establishment of a numbering administration arrangement as there will not be shared costs. Therefore, we believe the section 251(e)(2) requirements do not apply. Furthermore, even if section 251(e)(2) applies, we believe it is satisfied if we require each provider to bear its own costs because each provider's costs will be proportional to the size and quality of its network. We seek comment on this analysis. 6.

Bounce-Back Messages 43. We seek comment on whether and in what circumstances to require covered text providers to send automatic bounce-back messages where text-to-988 service is unavailable. Throughout the ongoing roll-out of text-to-911 services across the U.S., the Commission has required covered text providers to send an automatic reply, or bounce-back, text message when a consumer attempts to send a text message to a PSAP by means of the 3-digit code â911â and the covered text provider cannot deliver the text because (1) the consumer is located in an area where text-to-911 is not available, or (2) the covered text provider either does not support text-to-911 generally or does not support it in the particular area at the time of the consumer's attempted text. Unlike in the text-to-911 context, where availability varies by geography and is based on whether the local PSAP can receive texts, our proposals herein would require covered text providers to support nationwide texting to the Lifeline via the 988 3-digit code on a uniform nationwide deadline. If we were to adopt our proposal, should we nonetheless require bounce-back messages?.

If so, when and under what circumstances?. Should we require covered text providers to make available bounce-back messages sooner than we require implementation of text-to-988?. Would requiring bounce-back messages be appropriate if we adopt a uniform nationwide deadline for text-to-988 capability later than July 16, 2022âthe uniform nationwide deadline for covered providers to support calls to 988?. Would requiring bounce-back messages be appropriate if we adopt exemptions or extensions for some providers?. 44.

We seek comment on the potential benefits and costs of a bounce-back requirement. In the text-to-911 context, the Commission determined that âthere is a clear benefit and present need for persons who attempt to send emergency text messages to know immediately if their text cannot be delivered to the proper authorities,â noting that feedback where text-to-911 is not available may be lifesaving by directing a person to seek out an alternative means of communicating with emergency services. Is that the case here as well?. Because some individuals with disabilities may rely exclusively on texting for communicating, are there unique benefits of a bounce-back requirement for these individuals?. Since the Commission designated 988 as the 3-digit dialing code to access the Lifeline, efforts have been underway to educate the public about using this 3-digit code to reach help by telephone in times of mental health crisis, including its availability for routing voice calls to the Lifeline by July 16, 2022.

In the absence of a bounce-back, might such advertising confuse the public about the availability of texting to 988?. Would an automated bounce-back help to prevent such confusion?. Are there other advantages to requiring covered text providers to send bounce-back messages for attempts to text 988 where service is unavailable?. Are any providers included under the proposed âcovered text providersâ definition currently sending bounce-back messages to texts sent to 988?. 45.

What are the costs of requiring a bounce-back message?. What work or upgrades would be necessary for text service providers to implement an automatic bounce-back reply?. Given that covered text providers must provide a bounce-back in circumstances in which text-to-911 is unavailable, would adding a comparable bounce-back message for 988 be easier than if that existing infrastructure were not in place?. Would requiring text service providers to build bounce-back capabilities deter resources from more rapid deployment of text-to-988?. 46.

We seek comment on how requiring bounce-back messages may impact the public's ability to seek help from the Lifeline in times of mental crisis. What are the potential benefits to receiving an automatic bounce-back message when text-to-988 service is unavailable?. Are there any drawbacks to the public of requiring covered text providers to send bounce-back messages when text-to-988 is not available?. One commenter contends that if at-risk texters receive a bounce-back message regarding the unavailability of services, âthe risks of disengagement and adverse outcomes increase.â Do commenters agree with the assessment that an automatic bounce-back message will negatively impact individuals seeking help during a crisis?. Would a bounce-back message have the effect of making the sender more discouraged, such that it that could increase, not decrease, the likelihood of suicide?.

Alternatively, if there is no automatic reply, and the sender is left wondering whether the Lifeline received the text message, would that uncertainty also increase sender's likelihood of suicide?. We seek comment on whether the benefits of receiving an automatic bounce-back message outweigh the potential risk of disengagement. 47. If we were to adopt a bounce-back requirement, we seek comment on the specific requirement we should adopt. To align with the scope of the proposed outer bound text-to-988 capability requirements, we propose that if we were to adopt a bounce-back requirement, we would require all covered text providers to provide automatic bounce-back messages to text messages, as defined by our outer bound Start Printed Page 31412proposal herein, sent to 988 where text-to-988 service is unavailable.

We seek comment on this approach. Are there unique considerations for different technologies within the outer bound scope of text message that we should consider under our bounce-back message proposal, including such impact on technical implementation or costs?. Should we consider requiring covered text providers to send automatic bounce-back messages in reply to messages outside the scope of the outer bound definition?. Are there additional text or chat service providers that offer services beyond the proposed outer bound definition that we should include within the scope of our proposed bounce-back requirement?. Should we limit any bounce-back requirement to covered text providers, as proposed, or should the requirement sweep more broadly?.

CTIA asserts that text-to-988 implementation should be consistent with existing SMS capabilities. Should any bounce-back requirement we may explore likewise remain consistent with SMS?. Is sending a bounce-back message in response to texts to 988 feasible on legacy SMS systems?. We seek comment on the impact including other text or chat service providers, or other forms of messages, may have on the implementation costs, technical feasibility, and timeframe for our proposed bounce-back message requirements. 48.

Should we adopt a bounce-back requirement, we seek comment on whether and how to expand on the circumstances in which a covered text provider must provide a bounce-back message due to unavailability of text-to-988. In the text-to-911 context, when a customer is roaming away from his or her âhome networkâ (i.e., the network of the customer's mobile carrier), the CMRS provider operating the customer's home network is nonetheless responsible for providing a bounce-back message when required. And the provider operating the network on which the customer is roaming must not impede the bounce-back response by the home network operator. We seek comment on adopting a similar requirement here. Additionally, we anticipate that there may be circumstances in which the Lifeline is unable to receive and respond to texts, including where demand may exceed its capacity to respond.

In instances amounting essentially to a âbusy signalâ for text delivery, are covered text providers capable of determining that the text cannot be delivered to 988?. Would covered text providers be able to determine if a text to 988 is undeliverable due to the Lifeline's inability, whether temporary or sustained, to receive and respond to the texts?. Or should we establish a mechanism whereby the Lifeline may inform providers of a temporary suspension of text-to-988 service, and should the bounce-back requirement apply until the suspension is lifted?. Lastly, we seek comment on considerations, either within the control of the covered text provider or the Lifeline's administrators, in which a message from an individual in crisis attempting to reach 988 may not be delivered, and therefore may benefit from receipt of a bounce-back message directing the individual to contact 988 by alternative means. Are there additional circumstances where we should require covered text providers to send bounce-back messages in response to 988 texts?.

49. If we were to adopt a bounce-back requirement, we propose to adopt the same exceptions to our bounce-back notification requirement for text-to-988 as currently exist for the Commission's text-to-911 rules. If we adopt that same approach, a covered text provider would not be required to provide an automatic bounce-back message when. (1) Transmission of the text message is not controlled by the provider. (2) a consumer is attempting to text 988, through a text messaging application that requires CMRS service, from a non-service initialized handset.

(3) the text-to-988 message cannot be delivered due to a failure in the Lifeline's routing network that has not been reported to the provider. Or (4) a consumer is attempting to text 988 through a device that is incapable of sending texts via 3-digit codes, provided that the software for the device cannot be upgraded over the air to allow text-to-988. We seek comment on this approach. Are there other situations where a covered text provider should not be required to send bounce-back messages to consumers attempting to text to 988?. Furthermore, we seek comment on the circumstances in which the provider of a pre-installed or downloaded interconnected text application would be considered to have âcontrolâ over the transmission of text messages for the purposes of any requirements we adopt.

If a user or third party modifies or manipulates the application after it is installed or downloaded so that it no longer supports bounce-back messaging, should the application provider be presumed not to have control?. 50. If we adopt a bounce-back requirement, should we specify or provide guidance regarding the content of the bounce-back message, and if so, what should we specify or encourage?. Similar to automatic messages sent in response to undeliverable texts to 911, we propose that any bounce-back messages to consumers attempting to text 988 would not require all covered text providers to use identical wording for their automatic responses. Rather, if we were to adopt a bounce-back requirement, we propose that a covered text provider would be deemed to have met its obligation so long as the bounce-back message to 988 includes, at a minimum, two essential points of information.

(1) That text-to-988 is not available. And (2) identify other means to reach the Lifeline, such as by telephone. We seek comment on this approach and on alternatives. We seek comment on what role our federal partners and non-governmental mental health organizations could play in developing best practices regarding the content of messages. 7.

Role of the Substance Abuse and Mental Health Services Administration and the Department of Veterans Affairs 51. Although the Commission has an important role to play in expanding access to crisis counseling through its implementation of 988, SAMHSA and the VA are ultimately responsible for ensuring the continued success of these lifesaving resources. As such, we propose to direct the Bureau to continue to coordinate the implementation of 988 with SAMHSA and the VA, including any issues pertaining to the delivery of text messages to 988. 52. We seek comment on this proposal.

How we can best support the work of our federal partners in administering the Lifeline and Veterans Crisis Line?. We recognize that many commenters have stressed the importance of ensuring adequate funding and staffing for the Lifeline and the Veterans Crisis Line over the course of this proceeding. Although these issues are beyond our jurisdiction, are there unique considerations pertaining to staffing, funding, or the availability of other resources at the Lifeline or Veterans Crisis Line that we should be aware of as we consider adopting rules to require the delivery of text messages to 988?. How should we account for the possibility that text-to-988 may be popular and increase demands on the Lifeline and Veterans Crisis Line?. What resources will be needed for the Lifeline and Veterans Crisis Line to ensure that text-to-988 is a success?.

How should we account for our federal partners' budget cycles?. We are cognizant of the potential burdens our proposals may impose upon our federal partners, Start Printed Page 31413including personnel, equipment, and resource allocation, and we seek comment on the impact the possible implementation solutions may have on SAMHSA and the VA when supporting text-to-988 service. To that end, we intend to coordinate with SAMHSA and the VA, and we encourage other industry stakeholders in the wireless and texting service industry to coordinate with these agencies as well. Assuming that our adoption of rules implementing text-to-988 capability will require expenditure of additional resources by SAMHSA and the VA, are there ways that we can structure our rules to minimize the burden on our federal partners?. Are there any steps we should take to deter misuse of text-to-988, so as to limit the unnecessary expenditure of resources by our federal partners?.

Are there any solutions that have been employed in other contexts, such as text-to-911, that we or others should adapt here to deter misuse of text-to-988?. 53. In addition, we encourage SAMHSA and the VA to coordinate with outside organizations that have expertise in providing crisis counseling via text message as they develop the infrastructure to receive and respond to text messages which may one day be delivered to the Lifeline and Veterans Crisis Line via 988. Many commenters in this proceeding have urged collaboration between private entities like the Trevor Project and federal agencies providing similar services. We therefore seek comment on how to facilitate such coordination across federal agencies and the private sector, as we work towards our shared goal of ensuring that all Americans have ready access to mental health counseling and support services.

C. Legal Authority 54. We propose concluding that we have the authority to adopt the rules proposed and for which we seek comment in this further notice of proposed rulemaking under Title III of the Act and the Twenty-First Century Communications and Video Accessibility Act (CVAA). We seek comment on these and any other sources of authority available to us. In particular, we seek comment on whether, and if so, to what extent, our numbering authority under section 251(e) of the Act provides an additional source of authority for the rules proposed and for which we seek comment in this further notice of proposed rulemaking.

Finally, we also seek comment on whether we should employ our ancillary authority. We note that, in our preliminary review, the National Suicide Hotline Designation Act of 2020 does not provide additional support forânor does it hinderâthe actions proposed in this further notice of proposed rulemaking. We seek comment on these views. 55. The rules we propose and for which we seek comment in this further notice of proposed rulemaking are analogous to those the Commission has adopted to facilitate text-to-911 communications, which relied, in part, on the Commission's Title III authority over wireless carriers, including sections 301, 303, 307, 309, and 316.

We propose concluding that, with respect to CMRS providers, Title III provides us with appropriate authority to require wireless carriers to support text-to-988 service and to require delivery of a bounce-back message to consumers in cases where delivery of a text to 988 cannot be completed. As the Supreme Court has long recognized, Title III grants the Commission a âcomprehensive mandateâ regarding regulation of spectrum usage, and courts have routinely found that Title III provides the Commission with âbroad authority to manage spectrum. . . In the public interest.â As we explain, we believe the rules we propose in this further notice of proposed rulemaking are likely to have significant public interest benefits.

And, the Commission has previously found that its Title III licensing authority supported adoption of a similar set of obligations in the text-to-911 context. Therefore, we believe that with respect to CMRS providers, Title III provides sufficient authority here. We note that, following the release of the Text-to-911 Order, the Commission released a Declaratory Ruling classifying SMS and MMS services as âinformation servicesâ under the Act. However, as the Commission explicitly noted in the Declaratory Ruling, this determination âdoes not affect the general applicability of the spectrum allocation and licensing provisions of Title III and the Commission's rulesâ to SMS and MMS services, nor does it affect the specific application of sections 301, 303, 307, 309, and 316 to the Commission's text-to-911 rules. We seek comment on this analysis.

56. With respect to interconnected text messaging service providers, we propose to find that the CVAA provides us with authority to adopt the proposals in this further notice of proposed rulemaking, as some commenters in this proceeding suggest. Congress enacted the CVAA to increase the accessibility of modern communications technologies to people with disabilities, including access related to emergency services, and the Commission relied, in part, on this authority when it adopted similar text-to-911 requirements. The CVAA provides the Commission with authority to âachiev[e] equal access to emergency services by individuals with disabilities, as a part of the migration to a national internet protocol-enabled emergency network.â In particular, the CVAA granted the Commission the authority to adopt regulations to implement recommendations proposed by the Emergency Access Advisory Committee established by the CVAA, which concern access to 911 and NG911 services, and to adopt âother regulationsâ as are necessary to achieve reliable, interoperable communication that ensures access by persons with disabilities to an IP-enabled emergency services network. We tentatively conclude that the CVAA provides authority for our proposals because access to 988 is similar to 911 access for the purposes of our CVAA authority.

We seek comment on this tentative conclusion. Do commenters agree that access to the Lifeline or Veterans Crisis Line through 988 constitute âaccess to emergency servicesâ under the CVAA?. Do commenters agree that text-to-988 is necessary to achieve reliable, interoperable communication that ensures access by persons with disabilities to an IP-enabled emergency services network?. More generally, does the CVAA provide us with authority to adopt the rules proposed in this further notice of proposed rulemaking?. 57.

We seek comment on any other sources of authority available to the Commission to adopt the proposals detailed in this further notice of proposed rulemaking. In particular, we seek comment on whether our section 251(e) authority over numbering provides authority to require support for text-to-988 service. Section 251(e)(1) of the Act grants us âexclusive jurisdiction over those portions of the North American Numbering Plan that pertain to the United Statesâ and provides that numbers must be made âavailable on an equitable basis.â This provision gives the Commission âauthority to set policy with respect to all facets of numbering administration in the United States.â The Commission found in the 988 Report and Order that section 251(e) provides us with the ability to regulate interconnected and one-way VoIP providers that make use of numbering resources when they connect with the PSTN. We seek comment on whether our numbering authority provides an additional, independent basis to adopt rules with respect to CMRS providers Start Printed Page 31414and interconnected text messaging services. 58.

We also seek comment on the Commission's authority to mandate location information with text-to-988 service. Section 222 of the Communications Act, as amended, provides strong legal protections for customer proprietary network information (CPNI), including geolocation information. Section 222(d) provides exceptions to allow CPNI and call location data to be shared for âemergency services.â We seek comment on whether this could encompass the transmission of geolocation information with 988 calls. Should we choose to require covered text providers to include location information with texts to 988, does section 222 authorize the disclosure of location information with texts to 988?. Are there other privacy concerns that we should consider with regard to texts to 988?.

59. Finally, we seek comment on whether exercise of our ancillary authority would be necessary or appropriate to support any of our proposed rules. The Commission relied in part on ancillary authority to apply the bounce-back notification requirement to providers of interconnected text messaging services when it adopted text-to-911 requirements. Would a similar finding be appropriate with respect to any aspect of our text-to-988 rules?. D.

Benefits and Costs of Text-to-988 60. We expect to find that the benefits of requiring service providers to support text-to-988 service will exceed the costs of implementation. We seek comment on this proposal, and any specific data regarding both the benefits of facilitating access to the Lifeline via texts to 988 and on the costs or burdens implementation of text-to-988 may impose upon covered text providers. 61. Suicide causes shock, anguish, grief, and guilt among victims' families and friends.

Suicide attempts exact a similarly heavy toll on the community and the victim. The long-lasting damage from mental distress and suicide can extend deep into communities. As outlined above, we preliminarily believe that enabling text-to-988 service will improve access to lifesaving resources for individuals contemplating suicide or experiencing mental health crises, especially for members of at-risk communities such as young people, LGBTQ, people of color, and individuals with disabilities, thereby saving lives. By expanding access to counseling, text-to-988 may help break the cycle of pain, suffering, and suicide. We seek comment generally on these and other important benefits that may follow from increased access to mental health resources via texting to 988.

62. We further seek comment on ways to quantify these benefits. Of course, the benefits to individuals who the Lifeline or Veterans Crisis Line places on a path to recovery, much less to their families and friends, cannot be reduced to dollars and cents. That being said, even if text-to-988 service could annually place just one-per-one-thousand suicide victims on a path to long-term recovery, the economic gain would be $19.2 million in any single year, for a present-value of $78.7 million over five years and $134.9 million over ten years. In estimating benefits, we focus on teens and individuals with disabilities, as individuals in these groups are more likely to use a text-to-988 capability.

Based on the most recent CDC data from 2015-2019, 11,283 youth (ages 15-19) and an estimated 13,101 individuals who are deaf, hard of hearing, deafblind or speech disabled committed suicide (using an estimated incidence among adults of 6%), or an average of more than 2,000 per year for each group. To calculate the estimated benefits for a single year, we multiply the annual average by 0.1% and the VSL (2,000 * 0.001 * $9.6 million = $19.2 million). We discount over five years and ten years at a 7% discount rate. We seek comment on this analysis. 63.

Our proposed analysis does not examine certain categories of benefits. For example, we have not estimated the cost savings from medical expenses and loss-of-work avoided through reduced suicides and suicide attempts. We also have not estimated the cost savings of reduced burdens on PSAPs, police, ambulance, and fire and rescue services, which currently respond to some 911 texts that will be routed to the Lifeline, where they will be more effectively and efficiently de-escalated or otherwise resolved. Moreover, we have not examined the benefits of text-to-988 usage by every demographic group. For example, smartphone ownership and suicide are particularly common in younger age groups.

According to the Common Sense Census. Media Use by Tweens and Teens, 2019, 53% of children have their own smartphone by age 11, and 69% have one at age 12. Currently, our estimated benefits analysis looks at youth ages 15-19. To accurately estimate these benefits, we seek comment on how broadly we should define youth who may text to 988. Relatedly, there is the possibility that adults without hearing or speech disabilities may rely exclusively on text-to-988 for added privacy or convenience, meriting inclusion in our benefit estimates.

We also seek comment on ways to better assess the long-term impact of text-to-988 service. Without longitudinal studies evaluating the long-term effectiveness of suicide call centers, we cannot pinpoint how many suicides text-to-988 will prevent in the long run. Available survey-based studies, however, reveal call centers can substantially reduce suicides during the initial call and follow-up periods. We seek comment on the types and magnitudes of these and other benefits not covered in this further notice of proposed rulemaking, as well as any overlooked categories of costs. 64.

In the Text-to-911 proceeding, the Commission estimated that the total cost for covered providers to implement text-to-911 service amounted to less than $21 million. The costs of nationwide deployment of text-to-911 fell into three categories. CMRS and PSAP system cost components. Interconnected text providers' software upgrades. And bounce-back messaging application alterations and server platform modifications.

Assuming that all or most of the software and equipment necessary to receive and transmit 911 texts will again be needed to deploy text-to-988, we expect that the implementation costs for text-to-988 service will be comparable to the costs for text-to-911 service. Using cost estimates from the Text-to-911 proceeding as a model, we estimate it will cost $19,024,916 for CMRS providers to implement text-to-988, $613,275 for interconnected text messaging service providers to implement text-to-988, and $7,310,340 for Lifeline to route texts to local crisis centers. We convert the estimate for CMRS providers to implement text-to-911 service to 2021 dollars by multiplying by a Consumer Price Index (CPI) factor of 1.16, then discounting over five years at a 7% discount rate. Similarly, we convert the estimate for interconnected text messaging providers to implement text-to-911 service into 2021 dollars by using a CPI factor of 1.105. To soberly assess Lifeline capability, we assume that 100% of Lifeline call centers may require SMS upgrades and thus multiply PSAP software estimates by 2.22.

To estimate the costs to equip the more than 180 Lifeline crisis centers, we calculate an average cost based on an estimated per PSAP cost of $40,613 (=($263,277,595 + $12,891,283)/6,800), for a total of $7,310,340 (=180 * $40,613). Therefore, we preliminarily estimate that total costs for implementing text-to-988 will be approximately $27 million. We seek Start Printed Page 31415comment on this analysis, including our preliminary assumption that text-to-911 software and equipment can be leveraged for texting to 988. Do commenters agree with CTIA that there are âsignificant technical and policy differencesâ between 988 and 911 service, and if so, how might those differences impact our evaluation?. Furthermore, we seek comment on whether cost estimates for PSAPs from the Text-to-911 proceeding reflect an appropriate estimate for costs to the Lifeline or Veterans Crisis Line.

Are there other costs borne by the Lifeline or Veterans Crisis Line needed to implement text-to-988 service?. 65. We preliminarily assume that some costs may be streamlined or reduced due to the previous implementation of text-to-911, which may be leveraged to facilitate text-to-988 capability and seek comment on this assumption. As a result, we anticipate that costs for covered text providers to implement text-to-988 may be less than what we estimate above and seek comment on this finding. We further seek comment on what extent covered text providers may rely upon existing text-to-911 services and how to quantify the costs needed to upgrade such systems to support text-to-988.

66. Deterring suicide has benefits that simply cannot be reduced to numbersâsaving lives has value beyond measure. While recognizing this fact, to illustrate how the benefits of our proposal relate to the more aptly quantified costs, we attempt to estimate the quantifiable value of suicide prevention using a measure of collective willingness to pay. We propose calculating that the level of suicide prevention needed to generate benefits exceeding our preliminary estimate of $27 million in text-to-988 costs is a total of four suicides avoided over five years. Specifically, the level of teen suicide prevention needed to generate benefits exceeding $27 million is one per 2,821, and the level of suicide prevention among individuals with disabilities to generate benefits exceeding $27 million is one per 3,275.

Even assuming that text-to-988 prevented no suicides in its inaugural year as the service rolled out but prevented one suicide in each of the ensuing four years, measured in terms of the public's willingness to pay for that mortality reduction, the present value of the benefit would be $30.39 million, more than three million dollars greater than the total cost. The present value would be an uneven stream of payments of $9.6 million ($0 in Year 1 + $9.6 million per year in Year 2 through Year 5) at a 7% discount rate. We seek comment on our analysis. 67. Using break-even points and highly attainable suicide reductions that are well below those suggested by survey studies, we estimate that the benefits of text-to-988 will far exceed the costs.

Pooling teenagers and individuals with disabilities, we estimate that text-to-988 would need to prevent one suicide out of every six thousand in order to break-even in the first five years of deployment. Slightly raising the bar to preventing one suicide per one thousand, we further estimate that the more than $157.5 million estimated benefit from modestly reducing suicides in two vulnerable populations far exceeds the text-to-988 deployment costs of $19.6 million incurred by CMRS and interconnected text providers. Even if sizable Lifeline deployment costs are added, increasing estimated total cost to nearly $27 million, the estimated benefits of text-to-988 remain greater by a multiple of nearly six. Over ten years, the benefits rise to $269.8 million, exceeding costs by a multiple of nearly ten. We seek comment on these estimates.

We also seek comment on the methods and underlying benefits and costs estimates, including those submitted by third parties, used to arrive at our overall proposed conclusion. II. Initial Regulatory Flexibility Analysis 1. As required by the Regulatory Flexibility Act of 1980, as amended (RFA), the Commission has prepared this Initial Regulatory Flexibility Analysis (IRFA) of the possible significant economic impact on small entities by the policies and rules proposed in this Implementation of the National Suicide Hotline Improvement Act of 2018 further notice of proposed rulemaking (FNPRM). The Commission requests written public comments on this IRFA.

Comments must be identified as responses to the IRFA and must be filed by the deadlines for comments provided on the first page of the further notice of proposed rulemaking. The Commission will send a copy of the further notice of proposed rulemaking, including this IRFA, to the Chief Counsel for Advocacy of the Small Business Administration (SBA). In addition, the further notice of proposed rulemaking and IRFA (or summaries thereof) will be published in the Federal Register. A. Need for, and Objectives of, the Proposed Rules 2.

In this FNPRM, the Commission proposes and seeks comment on requiring CMRS providers and providers of interconnected text messaging services that enable consumers to send text messages to, and receive text messages from, the PSTN (covered text providers) to enable delivery of text messages to 988. The Commission proposes to require 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 proposed 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. Legal Basis 3.

The legal basis for any action that may be taken pursuant to this FNPRM is contained in sections 201, 251, 301, 303, 307, 309, and 316 of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251, 301, 303, 307, 309, 316. C. Description and Estimate of the Number of Small Entities to Which the Proposed Rules Will Apply 4. 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 proposed rules and by the rule revisions on which the Notice seeks comment, if adopted.

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.

5. 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 Small Business Administration's (SBA) 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 Start Printed Page 31416States, which translates to 30.7 million businesses. 6. 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.

7. 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 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 50,000. Accordingly, based on the 2017 U.S.

Census of Governments data, we estimate that at least 48,971 entities fall into the category of âsmall governmental jurisdictions.â 8. 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 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. 9. 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 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.

10. 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. 11. 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. 12. We have included small incumbent LECs in this present RFA analysis. As noted above, a âsmall businessâ under the RFA is one that, inter alia, meets the pertinent small business size standard (e.g., a telephone communications business having 1,500 or fewer employees), and âis not dominant in its field of operation.â The SBA's Office of Advocacy contends that, for RFA purposes, small incumbent LECs are not dominant in their field of operation because any such dominance is not ânationalâ in scope.

We have therefore included small incumbent LECs in this RFA analysis, although we emphasize that this RFA action has no effect on Commission analyses and determinations in other, non-RFA contexts. 13. 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. Start Printed Page 31417Consequently, the Commission estimates that the majority of interexchange service providers are small entities. 14. 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. 15. Toll Resellers.

The Commission has not developed a definition for Toll Resellers. The closest NAICS Code Category is Telecommunications 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.

16. 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. 17. 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.

Mobile virtual networks operators (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. 18. Wireless Telecommunications Carriers (except Satellite).

Neither the SBA nor the Commission has developed a size standard specifically applicable to Wireless Carriers and Service Providers. The closest applicable is Wireless Telecommunications Carriers (except Satellite), which the SBA small business size standard is such a business is small if it 1,500 persons or less. 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 had employment of 999 or fewer employees and 12 had employment of 1000 employees or more.

Thus under this category and the associated size standard, the Commission estimates that the majority of Wireless Carriers and Service Providers are small entities. 19. According to internally developed Commission data for all classes of Wireless Service Providers, there are 970 carriers that reported they were engaged in the provision of wireless services. Of this total, an estimated 815 have 1,500 or fewer employees, and 155 have more than 1,500 employees. Thus, using available data, we estimate that the majority of Wireless Carriers and Service Providers can be considered small.

20. 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 Start Printed Page 31418systems, for transmission to viewers.â 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. 21. 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 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. 22. 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. 23. 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 voice over internet protocol (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. 24. 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, 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 or fewer employees. 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. 25. 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. 26. 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. 27. Internet Service Providers (Broadband). Broadband internet service providers include wired (e.g., cable, 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 Start Printed Page 31419that 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. 28. Internet Service Providers (Non-Broadband). Internet access service providers such as Dial-up internet service providers, 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.

29. 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 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. D. Description of Projected Reporting, Recordkeeping, and Other Compliance Requirements for Small Entities 30.

The FNPRM proposes and seeks comment on rules to require covered text providers to support text messaging to 988. It tentatively concludes that text-to-988 functionality will greatly improve consumer access to the Lifeline, particularly for at-risk populations, and thereby save lives. The proposed rules would 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 FNPRM proposes (1) establishing a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support. And (2) directing 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.

The FNPRM seeks comment on this proposal. The Commission preliminarily believes that applying the same rules equally to all entities in this context is necessary to alleviate potential consumer confusion from adopting different rules for different covered text providers. The Commission proposes that the costs and/or administrative burdens associated with the rules will not unduly burden small entities. E. Steps Taken To Minimize the Significant Economic Impact on Small Entities, and Significant Alternatives Considered 31.

The RFA requires an agency to describe any significant alternatives that it has considered in reaching its proposed approach, which may include the following four alternatives (among others). (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.

32. In the FNPRM, the Commission seeks comment from all entities, including small entities, regarding the impact of these proposed rules on small entities. The Commission seeks comment on the impact, cost or otherwise, that requiring text messaging to 988 capability will impose on regional and rural carriers and small businesses. The Commission also seeks comment on whether to adopt any exemptions for small businesses and if so, under what circumstances. The Commission asks and will consider alternatives to the proposals and on alternative ways of implementing the proposals.

F. Federal Rules That May Duplicate, Overlap, or Conflict With the Proposed Rules 33. None. III. Procedural Matters 34.

Ex Parte Rules. This proceeding shall be treated as a âpermit-but-discloseâ proceeding in accordance with the Commission's ex parte rules. Persons making ex parte presentations must file a copy of any written presentation or a memorandum summarizing any oral presentation within two business days after the presentation (unless a different deadline applicable to the Sunshine period applies). Persons making oral ex parte presentations are reminded that memoranda summarizing the presentation must (1) list all persons attending or otherwise participating in the meeting at which the ex parte presentation was made, and (2) summarize all data presented and arguments made during the presentation. If the presentation consisted in whole or in part of the presentation of data or arguments already reflected in the presenter's written comments, memoranda or other filings in the proceeding, the presenter may provide citations to such data or arguments in his or her prior comments, memoranda, or other filings (specifying the relevant page and/or paragraph numbers where such data or arguments can be found) in lieu of summarizing them in the memorandum.

Documents shown or given to Commission staff during ex parte meetings are deemed to be written ex parte presentations and must be filed consistent with Rule 1.1206(b). In proceedings governed by Rule 1.49(f) or for which the Commission has made available a method of electronic filing, written ex parte presentations and memoranda summarizing oral ex parte presentations, and all attachments thereto, must be filed through the electronic comment filing system available for that proceeding, and must be filed in their native format (e.g., .doc, .xml, .ppt, searchable .pdf). Participants in this proceeding should familiarize themselves with the Commission's ex parte rules. 35. Initial Regulatory Flexibility Analysis.

Pursuant to the Regulatory Flexibility Act (RFA), the Commission has prepared an Initial Regulatory Flexibility Analysis (IRFA) of the possible significant economic impact on small entities of the policies and actions considered in this FNPRM. Written public comments are requested on this IRFA. Comments must be identified as responses to the IRFA and must be filed by the deadlines for comments on the FNPRM. The Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, will send a copy of the FNPRM, including the IRFA, to the Chief Counsel for Advocacy of the Small Business Administration.Start Printed Page 31420 36. Comment Filing Procedures.

Pursuant to Â§Â§â1.415 and 1.419 of the Commission's rules, 47 CFR 1.415, 1.419, interested parties may file comments and reply comments on or before the dates indicated on the first page of this document. Comments may be filed using the Commission's Electronic Comment Filing System (ECFS). See Electronic Filing of Documents in Rulemaking Proceedings, 63 FR 24121 (1998). Electronic Filers. Comments may be filed electronically using the internet by accessing ECFS.

Https://www.fcc.gov/âecfs/â. Paper Filers. Parties who choose to file by paper must file an original and one copy of each filing. Filings can be sent by commercial overnight courier, or by first-class or overnight U.S. Postal Service mail.

All filings must be addressed to the Commission's Secretary, Office of the Secretary, Federal Communications Commission. Commercial overnight mail (other than U.S. Postal Service Express Mail and Priority Mail) must be sent to 9050 Junction Drive, Annapolis Junction, MD 20701. U.S. Postal Service first-class, Express, and Priority mail must be addressed to 45 L Street NE, Washington, DC 20554.

Effective March 19, 2020, and until further notice, the Commission no longer accepts any hand or messenger delivered filings. This is a temporary measure taken to help protect the health and safety of individuals, and to mitigate the transmission of erectile dysfunction treatment. See FCC Announces Closure of FCC Headquarters Open Window and Change in Hand-Delivery Policy, Public Notice, 35 FCC Rcd 2788 (OS 2020), https://www.fcc.gov/âdocument/âfcc-closes-headquarters-open-window-and-changes-hand-delivery-policy. 37. 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). 38. Paperwork Reduction Act of 1995 Analysis. This document may contain proposed new or modified information collection requirements.

The Commission, as part of its continuing effort to reduce paperwork burdens, invites the general public and the Office of Management and Budget (OMB) to comment on the information collection requirements contained in this document, as required by the Paperwork Reduction Act of 1995, Public Law 104-13. In addition, pursuant to the Small Business Paperwork Relief Act of 2002, Public Law 107-198, we seek specific comment on how we might further reduce the information collection burden for small business concerns with fewer than 25 employees. 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. It is ordered, pursuant to sections 201, 251, 301, 303, 307, 309, and 316 of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251, 301, 303, 307, 309, 316, that the FNPRM in WC Docket No. 18-336 is adopted.

41. It is further ordered that the Petition for Reconsideration filed by Communications Equality Advocates is granted in part to the extent described herein. 42. It is further ordered that the Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, shall send a copy of this FNPRM, including the Initial Regulatory Flexibility Analysis, to the Chief Counsel for Advocacy of the Small Business Administration. Start List of Subjects Communications common carriersTelecommunicationsTelephone End List of Subjects Start Signature Federal Communications Commission.

Marlene Dortch, Secretary. End Signature Proposed Rules For the reasons discussed in the preamble, the Federal Communications Commission proposes to amend 47 CFR part 52 as follows.

Those closures tend to be low price viagra in rural areas. So, (residents in rural communities) are in a situation where if they need care, itâs even further away.â Additionally, he said, once those programs are in place, they need to be evaluated on how well they work. Many of the counties Mallinson worked with had no evaluation program in place, and those that did fell short of a proper program evaluation, having instead run research on satisfaction with the program.

ââThatâs very different from real program evaluation,â low price viagra he said. ÂOf course, program evaluation is hard and program evaluation can be expensive, so itâs another resource issue.â You Might Also LikeStart Preamble Start Printed Page 31404 Federal Communications Commission. Proposed rule.

In this document, the Federal Communications Commission proposes to require covered text providers low price viagra to support text messaging to 988, the 3-digit dialing code to reach the National Suicide Prevention Lifeline. We seek comment on this proposal and related issues, such as the text message formats that covered text providers must transmit to 988 and the timeframe for implementation. Comments are due on or before July 12, 2021, and reply comments are due on or before August 10, 2021.

You may low price viagra submit comments, identified by WC Docket No. 18-336, by any of the following methods. Federal Communications Commission's Website.

Http://apps.fcc.gov/âecfs/â. Follow the instructions for submitting comments. Mail.

Parties who choose to file by paper must file an original and one copy of each filing. Filings can be sent by commercial overnight courier, or by first-class or overnight U.S. Postal Service mail.

U.S. Postal Service first-class, Express, and Priority mail must be addressed to 45 L Street NE, Washington, DC 20554. Effective March 19, 2020, and until further notice, the Commission no longer accepts any hand or messenger delivered filings.

People with Disabilities. Contact the FCC to request reasonable accommodations (accessible format documents, sign language interpreters, CART, etc.) by email. FCC504@fcc.gov or phone.

202-418-0530 or TTY. 202-418-0432. For detailed instructions for submitting comments and additional information on the rulemaking process, see the SUPPLEMENTARY INFORMATION section of this document.

Start Further Info 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 the Commission's further notice of proposed rulemaking (FNPRM) in WC Docket No. 18-336, adopted on April 22, 2021 and released on April 23, 2021.

The full text of the document is available at https://docs.fcc.gov/âpublic/âattachments/âFCC-21-47A1.pdf. To request materials in accessible formats for people with disabilities (e.g., braille, large print, electronic files, audio format, etc.) or to request reasonable accommodations (e.g., accessible format documents, sign language interpreters, CART, etc.), send an email to fcc504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at (202) 418-0530 (voice) or (202) 418-0432 (TTY).

Synopsis I. Further Notice of Proposed Rulemaking A. Text-to-988 Can Save Lives 1.

In this FNPRM, we tentatively conclude that text-to-988 functionality will greatly improve consumer access to the National Suicide Prevention Lifeline (Lifeline), particularly for at-risk populations, and thereby save lives. We seek comment on this tentative conclusion, and on the benefits of text messaging as a means to facilitate access to the critical mental health resources offered by the Lifeline generally. 2.

We tentatively conclude that ensuring that Americans in crisis can text 988 is likely to save lives. In the 988 notice of proposed rulemaking, the Commission observed that âAmericans, particularly younger Americans, increasingly rely on texting to communicate,â and sought comment on how to account for this fact in establishing 988 as a nationwide 3-digit code for the Lifeline. In response, numerous experts in mental health and other fields have submitted comments in this proceeding underscoring the importance of texting as a vital communications medium by which many individuals may wish to obtain crisis counseling.

Further, many of these commenters noted that texting is particularly important for âmembers of vulnerable communities such as young people, low-income individuals, members of the LGBTQ community, and individuals who are deaf and hard of hearing.â We seek comment on our tentative conclusion and the assertions of these commenters regarding the importance of texting as a means to access the lifesaving resources offered by the Lifeline. 3. Just as âAmericans in crisis are in need of an easy-to-remember number to access the Lifeline's potentially life-saving resourcesâ by telephone, in our preliminary view Americans have a similarly strong need for an easy-to-remember number to reach the Lifeline by text.

Because stakeholders will widely advertise 988 as the telephone number for the Lifeline, we preliminarily believe that providing text access at the same number will generate synergies that enhance the value of efforts to promote 988. Conversely, we fear that if text-to-988 is not available, Americans in crisis may be confused by efforts to promote 988 as the Lifeline's telephone number and mistakenly believe that they can reach the Lifeline by texting 988, putting lives at risk. We seek comment on this preliminary analysis.

4. As the Commission noted in the 988 Report and Order, young people are disproportionately at risk for mental health crises. They are also more likely to be most comfortable communicating via text.

According to the National Alliance on Mental Illness, â[n]early 95% of teens have access to smart phones and say that texting is the primary way that they connect.â For this reason, the International Council for Helplines describes the increasing use of âchat and text services. . .

For those who are in a mental health crisis,â pointing to a recent survey indicating that â75% of millennials prefer texting over talking.â 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 As a result, Mental Health America argues, the âdata strongly support[â] the implementation of texting for providing resources to individuals experiencing suicidal ideation.â We seek comment on these views and whether adopting a text-to-988 mandate would provide particular benefits for young Americans. Are young people more inclined to seek help by text than by telephone, and if Start Printed Page 31405so, would making it easier to text the Lifeline save lives?. 5.

In our preliminary view, facilitating Lifeline accessibility by text message to 988 is also likely to provide significant benefits to many other at-risk communities as well, further justifying our proposed mandate. As the Commission explained in the 988 Report and Order, a broad range of American communities are disproportionately impacted by suicide, including Veterans, LGBTQ individuals, racial and ethnic minorities, and rural Americans. Many members of these affected communities may prefer to seek help through text messages.

For example, Mental Health America reports that data they collect demonstrate that individuals âwho identify as Black or African American are more likely to report that they would like to receive a phone number they can immediately call or text for helpâ than members of any other race or ethnicity. Do commenters agree with Mental Health America that making crisis counseling services available via text message âmay mean the difference between accessing psychological support and forgoing it, especially among youth of color?. Â Is Mental Health America correct that easy access to crisis services via text may be the difference between seeking and forgoing help for such groups, and if so would use of a 3-digit dialing code for the Lifeline make a significant difference in widespread understanding that such crisis services are available?.

In addition, as one commenter to the 988 notice of proposed rulemaking argued, adding text access to 988 could allow the Lifeline and Veterans Crisis Line âto more efficiently route those in need to specialized services,â further leveraging the expertise of organizations like the Trevor Project, which provides mental health support and counseling specific to the needs of LGBTQ youth. We preliminarily agree with this assessment and believe that establishing text access to 988 will complement the important work already being done by these and other private sector organizations, and further facilitate access to the lifesaving resources offered by the Lifeline and Veterans Crisis Line. We seek comment on these views and on the benefits of text-to-988 for at-risk groups.

Are there additional at-risk communities that may benefit from texting as an option to access the Lifeline?. 7. Likewise, we preliminarily believe that our tentative conclusion is further justified because implementing text-to-988 capability will provide substantial benefits for individuals with disabilities who uniquely rely on text-based media to communicate.

As the Communications Equality Advocates and others note, texting is an indispensable means of communication for individuals with disabilities. These individuals have increasingly adopted widely available text messaging platforms such as those offered by CMRS providers and interconnected text messaging services in lieu of specialized legacy devices. Further, texting may be the only means for such individuals to contact 988 directly and efficiently.

Access to telecommunications for individuals with disabilities is a longstanding Commission priority and statutory obligation, and facilitating access to 988 for deaf and hard of hearing individuals is a particularly important policy objective in light of studies finding a significantly increased risk of suicide among deaf and hard of hearing people when compared to those without hearing loss. We seek comment on these views and whether our proposal would ease access to lifesaving counseling for individuals with disabilities. Do commenters agree with the Communications Equality Advocates that the ability for individuals normally using text for the bulk of their communications, including people with disabilities, to access trained mental health professionals using text-to-988 will be of âparamount importanceâ?.

8. We tentatively conclude that the potential lifesaving benefits of expanding access to suicide prevention and mental health crisis services for all Americansâand particularly the at-risk groups discussed aboveâjustifies a text-to-988 mandate, and we seek comment on this view. 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 preliminarily believe that establishing text access to 988 will further advance these important objectives by providing mental health crisis counseling through a nationally available, easy-to-remember number that Americans will also associate with the telephonic Lifeline.

Do commenters agree with the Communications Equality Advocates that individuals in crisis âare likely to first use their preferred, familiar mode of communication to reach out for help?. Â We seek comment on this analysis, and on our proposed conclusion that a text-to-988 mandate is likely to offer substantial, lifesaving benefits to all Americans affected by mental health crises, particularly for many members of at-risk communities. Is a text-to-988 mandate likely to have a significant impact on the likelihood of Americans considering suicide or in a mental health crisis to contact the Lifeline?.

Would mandating text-to-988 amplify the benefits of promoting 988 as the telephone number for the Lifeline?. What are the costs or drawbacks to our proposal?. 9.

In our preliminary view, the Lifeline's soft launch of a texting capability is a significant changed circumstance that supports mandating text-to-988. When the Commission adopted the 988 Report and Order, the Lifeline was not capable of receiving or responding to text messages. The Commission, stating that it has no authority to require the Lifeline to develop texting capability, deferred âconsideration of mandating text-to-988 at this time so that we could revisit the issue promptly should the Lifeline develop integrated texting.â Now, the Lifeline is capable of responding to texts sent to the Lifeline.

The Lifeline's ability to respond to texts significantly strengthens the case for imposing a text-to-988 mandate on providers. We seek comment on this evaluation. 10.

We preliminarily expect many of the same lifesaving benefits from texting to 911 to accrue from texting to 988. In its comments in support of adopting a text-to-988 requirement, CTIA notes that text-to-911 functionality âhas saved countless lives and enabled public safety to keep pace with the modern Start Printed Page 31406communications preferences of consumers.â Given the parallels between the Commission's efforts to promote text access to 911 and our proposals in this FNPRM, are there lessons learned in the context of establishing text-to-911 capability that would be instructive here?. CTIA states that there are âsignificant technical and policy differences between the national 9-8-8 service that will be administered by the Lifeline and the local 9-1-1 services that are administered by thousands of PSAPs.â For example, unlike calls to 911, which carriers route to one of thousands of local PSAPs across the country based on the caller's geographic location, all calls to 988 are routed to a central toll free number, and are then directed within the Lifeline network to a local crisis center.

How might these or other differences between the 911 and 988 networks affect our proposal to adopt a text-to-988 requirement?. B. Proposed Implementation of Text-to-988 1.

Scope of Text-to-988 Requirement 11. Text Formats. We seek comment on an appropriate scope of text messages that covered text providers must transmit to 988.

At present, the Lifeline is capable of receiving text messages sent to the existing 10-digit number in âshort message serviceâ (SMS) format. The Commission's Truth in Caller ID rules define the term `short message service' or SMS as âa wireless messaging service that enables users to send and receive short text messages, typically 160 characters or fewer, to or from mobile phones and can support a host of applications.â We recognize, however, that our federal partners may incorporate additional capabilities for receiving and responding to text messages in the future. We seek to adopt a forward-looking, flexible scope that can expand with the capabilities of the Lifeline without unnecessarily burdening covered text providers by requiring support of formats that the Lifeline is not yet capable of receiving.

12. First, we propose to define the outer bound of text messages that covered text providers may be required to transmit to 988 based on the definition of âtext messageâ that Congress enacted in 2018 in the context of Truth in Caller ID requirements. The term âtext messageâ (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 or N11 service code.

(ii) includes a [SMS] message and a multimedia message service (commonly referred to as `MMS') message. And (iii) does not includeâ(I) a real-time, two-way voice or video communication. Or (II) a message sent over an IP-enabled messaging service to another user of the same messaging service, except a message described in clause (ii).

The Commission's Truth in Caller ID rules define MMS as âa wireless messaging service that is an extension of the SMS protocol and can deliver a variety of media, and enables users to send pictures, videos, and attachments over wireless messaging channels.â We seek comment on this proposed scope. We believe this definition has several advantagesâit incorporates multimedia messages. It is not limited to specific technologies.

And it reflects a recent determination by Congress, albeit in a different policy context. For the purpose of our text-to-988 rules, we propose adding âor 988â to the phrase â10-digit telephone number or N11 service codeâ so that text messages from the Lifeline identified by the 3-digit code 988 are included within the scope of covered text providers' obligations, and we seek comment on this proposal. We seek comment on whether using the Truth in Caller ID definition appropriately sets an outer bound that would achieve our goals of adopting a forward-looking, flexible scope that can expand with the capabilities of the Lifeline without unnecessarily burdening covered text providers.

13. We note that the Truth in Caller ID statutory definition of âtext messageâ excludes âreal-time, two-way voice or video communications,â as well as âmessages sent over. .

. IP-enabled messaging services to another user of the same messaging service.â If we adopt the Truth in Caller ID definition, we seek comment on how we should interpret each of these two exclusions here. Is there any reason to adopt a different interpretation of the relevant exclusions in this context compared to the Truth in Caller ID context?.

Â Would adopting the Truth in Caller ID definition of âtext message,â with the exclusions specified above, prevent us from possibly adding ânext-generationâ text messages to our requirements in the future?. 14. We also seek comment on alternative outer scopes of required texts.

For instance, should we adopt the scope of our text-to-911 rules, which require providers to route âa message, consisting of text characters, sent to the short code `911' and intended to be delivered to a PSAP by a covered text provider, regardless of the text messaging platform usedâ?. In the Text-to-911 Second Report and Order, the Commission identified SMS and MMS messages as examples of text messages included within the scope of this proposed rule. We seek comment on whether the Truth in Caller ID definition, the text-to-911 definition, or another definition offers the best model here.

We note that the Truth in Caller ID model is newer than the text-to-911 definition, originates with Congress rather than the Commission, and unlike the text-to-911 definition explicitly includes images, sounds, and other non-textual information. On the other hand, the Commission developed the text-to-911 definition in a more analogous policy context than the Truth in Caller ID definition. Do these or other considerations suggest that one or the other model is superior?.

What are the fundamental differences between SMS, MMS, and RCS?. How would the costs to implement SMS, MMS, and RCS differ?. The Commission has previously concluded that âmessages sent over other IP-enabled messaging services that are not SMS or MMSâsuch as [RCS]âare excluded fromâ the Truth in Caller ID definition of text message âto the extent such messages are sent to other users of the same messaging service.â Would it be necessary to modify the Truth in Caller ID definition for our purposes to ensure that it includes RCS or other next-generation services?.

16. We also seek comment on whether we should ensure that our proposed outer bound definition of text message encompasses RTT. Telecommunications for the Deaf and Hard of Hearing, Inc., et al.

Have urged us to mandate the ability to reach 988 by RTT, noting that the Commission âhas acknowledged the benefits of RTT in crisis situations such as `allow[ing] for interruption and reduc[ing] the risk of crossed messages Start Printed Page 31407because the. . .

Call taker is able to read the caller's message as it is being typed, rather than waiting until the caller presses the `send' key.â We seek comment on this assertion and other potential benefits and drawbacks of RTT to 988. We note that pursuant to the 2016 RTT Order, all wireless service providers are permitted to support RTT on their IP networks for purposes of 911 compliance (and for purposes of complying with the general accessibility requirements of Parts 6, 7, and 14 of the Commission's rules) as an alternative to supporting TTY communications over IP. In light of the deployment of such RTT capabilities in wireless IP networks, are there any impediments to wireless service providers routing RTT texts to the 988 number, in the event that Lifeline chooses to support RTT?.

Are there other reasons to include, or exclude, these types of applications from our definition?. Are there any text message formats that we should specifically exclude from the definition we adopt?. For example, in crafting the text-to-911 rules, the Commission chose to exclude from its requirements a variety of services, including ârelay service.

. . , mobile satellite service (MSS), and in-flight text messaging services,â as well as âtext messages that originate from Wi-Fi only locations or that are transmitted from devices that cannot access the CMRS network.â Should we adopt any similar exclusions here?.

17. Second, we seek comment on how to structure our delegation to the Bureau to ensure that covered text providers support formats within the scope of the definition we adopt that the Lifeline can receive. We propose, as an initial matter, requiring covered text providers to support transmission of SMS messages to 988, since that is what the Lifeline can presently receive.

We further propose directing the Bureau, after consultation with our federal partners at SAMHSA and the VA, to issue a Public Notice no less frequently than annually proposing and seeking comment on requiring covered text providers to transmit any new message formats to 988 that the Lifeline can receive and that are within the scope of the definition we adopt. If the Bureau proposes requiring implementation of a new message format, we further propose directing the Bureau, after notice and comment, to issue a second Public Notice, requiring covered text providers to transmit the new message format to 988 by a fixed deadline that we specify unless the record demonstrates that implementation is not technically feasible. We seek comment on this proposal.

Is technical feasibility an appropriate standard for exclusion, or do commenters recommend a different standard?. Should we have a standard for exclusion by the Bureau at all?. If we do not have a standard for excluding certain technologies, is notice and comment necessary?.

What is an appropriate implementation deadline for us to specify after the Bureau issues its Public Notice requiring implementation?. For instance, would six months be sufficient?. Should we instead allow the Bureau flexibility to set an appropriate deadline?.

Should we provide any further direction to the Bureau regarding the evaluation we propose to require?. 18. We also seek comment on structuring the scope of covered text messages differently.

For instance, should we simply adopt a definition of âtext messageâ and require covered text providers to support all such formats, regardless of whether the Lifeline can support that format presently?. Should we adopt a narrower definition of âtext messageâ that conforms to what the Lifeline can support at present?. While we appreciate the simplicity of either of these approaches compared to our proposal, how would commenters address our concern that the former is unnecessarily burdensome, and the latter is not adequately future-proofed?.

Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones.â We note that the term âcovered text providerâ used in this notice of proposed rulemaking differs from the term âcovered providersâ used in the rules the Commission adopted in the 988 Order, which refers to all telecommunications carriers, interconnected VoIP providers, and one-way VoIP providers. We seek comment on this proposal, and on any alternative approaches to the scope of entities that must establish text-to-988 transmission capability. For example, if we can apply the definition of âtext messageâ in the Truth in Caller ID rules to texting to 988, should we apply our text-to-988 rules to providers of âtext messaging services,â as defined in section 227 of the Act and our Truth in Caller ID rules?.

In that context, we define âtext messaging serviceâ as âa service that enables the transmission or receipt of a text message.â Is the Truth in Caller ID model preferable, for instance because it may incorporate a broader range of providers that support text messaging service, or is our proposal preferable, for instance because it is more specific?. We also seek comment on other possible models and scopes of covered providers. Would using âCMRS providersâ exclude services over certain spectrum bands or non-switched wireless services that transmit text messages to 988, and should we instead include âwireless carriers,â or a different term, in our definition of âcovered text providers?.

Â 20. Interconnected Text Messaging Services. In adopting the text-to-911 rules, the Commission observed that there are a variety of widely available text messaging services and platforms with different technological capabilities, including SMS, MMS, and âover-the-topâ (OTT) applications delivered over internet protocol (IP)-based mobile data networks.

As the Commission explained in the Text-to-911 Second Report and Order, âSMS requires use of an underlying carrier's SMS Center (SMSC) to send and receive messages from other usersâ while â[MMS]-based messaging makes use of the SMSC but also involves the use of different functional elements to enable transport of the message over IP networks.â A third category, OTT applications, may be offered by CMRS providers or third parties and allow consumers âto send text messages using SMS, MMS or directly via IP over a data connection to dedicated messaging servers and gateways.â These OTT services, which are often downloaded through mobile app stores, are increasingly popular with consumers and may be interconnected with the publicly Start Printed Page 31408switched telephone network (PSTN) or not. For purposes of the Commission's text-to-911 rules, interconnected text messaging applications enable consumers to âsend text messages to all or substantially all text-capable U.S. Telephone numbers and receive text messages from the same,â while non-interconnected applications âonly support communication with a defined set of users of compatible applications but do not support general communication with text-capable telephone numbers.â The Commission's text-to-911 rules include interconnected text messaging services but exclude non-interconnected applications because they do not provide the ability to communicate with text-capable U.S.

We seek comment on this approach. This approach is also analogous to the Commission's decision in the 988 Report and Order to apply to âproviders that access the [PSTN] on an interconnected basis to reach all Americansâ and any âproviders that access the [PSTN] on an interconnected basis to reach all Americans.â We note that the Commission's Truth in Caller ID rules provide an exemption for messages âsent over an IP-enabled messaging service to another user of the same messaging service, except [for an SMS or MMS message],â which similarly operates to exclude non-interconnected text messaging services. Since the services provided by the Lifeline require two-way communication and, by definition, non-interconnected text messaging applications cannot support two-way texting with âall or substantially all text-capable U.S.

Telephone numbers,â we believe it is unlikely that these services would be technically capable of supporting text-to-988 functionality. We seek comment on this view. Are there any tools available to the Commission to mitigate the potential for consumer confusion regarding the availability of text-to-988 across different text messaging platforms and technologies, particularly with respect to non-interconnected text messaging applications?.

2. Routing Texts to 988 22. We propose to require that covered text providers route covered 988 text messages to the Lifeline's current 10-digit number, 1-800-273-8255 (TALK), and we seek comment on this proposal.

This proposal is consistent with the Commission's decision for routing calls to 988 in the 988 Report and Order. In the 988 Report and Order, the Commission required âthat service providers transmit all calls initiated by an end user dialing 988 to the current toll free access number for the Lifeline,â finding that a centralized routing solution will allow for faster implementation of the 988 3-digit dialing code, lower costs to maintain 988 routing, and provide continued easy access to Lifeline by callers with disabilities. We preliminarily believe that there are similar benefits to routing texts to 988 to a single, centralized number and seek comment on this view.

Vibrant Emotional Health, the administrator of the Lifeline, argues in support of text-to-988 functionality integrated into the current Lifeline structure for routing voice and chat services, with oversight squarely within the role of the Lifeline's administrator. We seek comment on these assessments. 24.

We anticipate that requiring covered text providers to route to a single destination provides SAMHSA and the VA with flexibility to develop their own routing solutions among the local crisis centers, including adding new crisis centers in the future, as compared to requiring covered text providers to implement additional updates or routing changes as more centers are added. Callers to 1-800-273-8255 (TALK) can reach the Veterans Crisis Line by pressing option 1 to connect with one of three linked call centers in New York, Georgia, or Kansas. For other calls, calls to the Lifeline from anywhere in the United States are routed to the closest certified local crisis center according to the caller's area code or, should the closest center be overwhelmed by call volume, experience a disruption of service, or if the call is placed from part of a state not covered by Lifeline's network, the system automatically routes calls to a backup center.

We seek comment on this preliminary analysis. Do the current obligations to route voice calls to 988 to the Lifeline 10-digit number offer any opportunities for streamlining implementation or reducing costs associated with routing texts to 988 to the same number?. 25.

In the alternative, we seek comment on whether instead to follow a model more comparable to the text-to-911 architecture, whereby covered text providers route directly to a PSAP by requiring routing directly to a Lifeline local crisis center or to a Veterans Crisis Line crisis center. We anticipate that this approach would be significantly more costly than centralized routing and seek comment on this preliminary view. Is it easier to route texts to a single number than to individual crisis centers?.

Does that rationale apply here?. Are there benefits to routing texts to the individual crisis centers that are unique to text messages, such as providing localized support to the public in the vicinity of the crisis center?. What are the costs or drawbacks to covered text providers to route texts to the Lifeline 10-digit number versus the local crisis centers?.

Which approach will lead to speedier implementation, and how should that impact our analysis?. Is there another alternative approach, other than centralized routing or routing by crisis center, that we should consider?. 26.

Currently, Veterans and Service Members may dial the Lifeline to reach the Veterans Crisis Line via voice call, but the Lifeline texting service and the VA's short code texting service require contacting separate numbers. How should we account for this distinction in evaluating what rules to adopt to ensure that Veterans, Service Members, and their families are able to reach the Veterans Crisis Line directly and promptly?. We seek comment on whether and how we can act to facilitate integration of the Veterans Crisis Line's separate short code-based texting service into text-to-988 routing.

Are there specific actions that the Commission should take to allow users to text 988 and reach both the Lifeline and Veteran-specific assistance?. For instance, should we require covered text providers to provide an automated inquiry as to whether the texter is a Veteran or Service Member and route Start Printed Page 31409the text to either the existing Lifeline number or the existing short code for Veterans depending on the response?. Alternatively, would it be feasible to immediately prompt individuals texting to 988 to reply with the number â1â or âVetâ to be routed to the Veterans Crisis Line, similar to the experience for voice callers?.

27. We seek comment on whether we should require covered text providers to enable text-to-988 messages to include location information. As required by the National Suicide Hotline Designation Act of 2020, the Bureau will report to Congress on the costs and feasibility of providing location information with 988 calls on April 17, 2021.

In our preliminary view, given that we have not adopted a location mandate in the context of calls to 988, we believe it would be premature to adopt a mandate here, and we seek comment on this view. Does someone who sends a text message to 988 expect that their location will be transmitted to the Lifeline?. If consumers generally are aware that calls and texts to 911 include their location, would the same expectation apply to texts to 988?.

Would including location information deter at-risk individuals from texting to 988?. We seek comment on any complications inherent in this plan and on ways for covered text providers to work with SAMHSA and the VA to limit misrouting of texts. 3.

Implementation Timeframe for Text-to-988 28. Uniform Nationwide Deadline. We seek comment on an appropriate implementation timeframe for requiring covered text providers to support texting to 988 on a nationwide basis.

What drawbacks, if any, exist?. 29. Although we propose adopting a uniform nationwide deadline, we seek comment on whether we should adopt any extensions or exemptions for certain classes of providers or categories of text messages.

Should we adopt any extensions or exemptions for smaller, rural, or regional covered text providers?. If so, under what circumstances would such exemptions be appropriate?. Are there unique technical considerations that necessitate different implementation timelines for certain covered text providers?.

If so, what are they and why?. Are there any other considerations, such as any existing contractual obligations between our federal partners and other entities, that we should take into account in setting a deadline or deadlines?. 30.

Appropriate Deadline. We observe that CTIA and other commenters have previously argued that the Commission should not mandate text-to-988 before the Lifeline is capable of receiving and responding to texts, in part because the Lifeline's readiness to receive and respond to text messages is crucial to implementing text-to-988 successfully. We seek comment on this assertion.

Understanding that the Lifeline and Veterans Crisis Line successfully accepting and responding to text messages to 988 will require coordination between several stakeholders, we emphasize that the Commission will continue to coordinate closely with our federal partners, SAMHSA and the VA, in their efforts to enable crisis centers to respond to text messages to 988 and establish a reasonable implementation timeframe for text-to-988. We reiterate that the Commission does not wish to determine for SAMHSA how it allocates the Lifeline's resources, nor do we have the authority to require the Lifeline and its crisis centers to be capable of receiving and responding to text messages to 988. 31.

We seek comment on whether the Commission should require all covered text providers to support text-to-988 by July 16, 2022, the same implementation deadline for telecommunications carriers, interconnected VoIP providers, and one-way VoIP providers to support voice calls to 988. Is this technically, economically and operationally feasible?. Are there benefits to requiring a uniform implementation timeline for all voice and text communications to 988?.

We observe that some covered text providers have already implemented voice calling to 988. For those providers, will requiring covered text providers to implement text-to-988 on the same timeline as voice calling to 988 create any efficiencies, such as reducing fixed costs?. Is there an expectation that once 988 is deployed nationwide for voice communications that texting to 988 will be similarly available?.

Will a uniform implementation deadline discourage covered text providers from potentially supporting text to 988 before July 16, 2022?. Are there other potential benefits or drawbacks to uniform implementation deadlines for providers supporting voice calling and texting to 988?. 32.

Would it be less burdensome on providers working to implement 988 for voice calls in accordance with the 988 Report and Order?. Would a phased-in implementation timeline create consumer confusion regarding the availability of texting to 988?. If phased-in implementation deadlines would create consumer confusion, would requiring certain covered text providers to implement text-to-988 more quickly minimize consumer confusion?.

For example, if a covered text provider has already implemented voice calling to 988 and is advertising the availability of 988 to its customers, should the provider be required to implement text-to-988 before other covered text providers?. Are there other risks associated with a phased-in approach to an implementation timeline for voice and text communications to 988 as compared to uniform implementation timeline?. What, if any, phased-in deadlines should the Commission consider?.

33. We also seek comment on whether we should we adopt the same timeline for all covered text providers, regardless of the text messaging technology they use. Are there other preparedness concerns that we should take into Start Printed Page 31410consideration when determining an implementation timeframe?.

4. Technical Considerations 34. We seek comment on the specific technical considerations for covered text providers and equipment and software vendorsâincluding those providers who are rural or small businessesânecessary to implement text-to-988.

Network Upgrades. We seek comment on possible upgrades covered text providers would have to make to their networks to support text-to-988 capability. Since we propose to allow covered text providers to use any reliable method or methods to support text routing and delivery to 988, are any necessary network hardware or software upgrades small in scope?.

What specific components would require upgrading?. Can the current solutions to enable text-to-911 capability be leveraged to support text-to-988, or are the implementation options for covered text providers to support text-to-988 significantly different?. CTIA notes âthere are significant technical and policy differences between national 9-8-8 service that will be administered by the Lifeline and the local 9-1-1 services that are administered by thousands of PSAPs.â We seek comment on CTIA's view, especially with regard to any âsignificantâ technical differences.

Conversely, do commenters agree with Communications Equality Advocates that the costs to covered text providers for implementation of text-to-988 should be substantially lower than those associated with implementing text-to-911?. We seek further comment on the potential integration of text-to-988 solutions with existing systems, as well as other network considerations specific to covered text providers to support text-to-988. 36.

We also seek comment on whether there are unique network considerations for different text messaging service technologies within the proposed outer bound scope of text-to-988 service that impact implementation. CTIA comments that its member companies are âoptimistic about the technical feasibility of supporting text-to-988,â provided that implementation is consistent with existing capabilities of native SMS messaging. Do commenters agree?.

How does the evolution of texting services to new or future formats affect network upgrade options and implementation, and how should our rules account for such evolution?. Would requiring support for certain text messaging formats be more feasible for covered text providers to implement than others?. 37.

We specifically seek comment on the technical implementation capability and network upgrades necessary for interconnected text messaging service providers. Similar to the Commission's conclusion in the Text-to-911 proceeding, we anticipate that many interconnected text messaging service providers may choose to use a CMRS network-based solution to deliver texts to 988 and seek comment on this expectation. Have there been developments in text-to-911 delivery by interconnected text messaging service providers that such providers can use in text-to-988 implementation?.

In the text-to-911 context, the Commission's rules state. To the extent that CMRS providers offer Short Message Service (SMS), they shall allow access by any other covered text provider to the capabilities necessary for transmission of 911 text messages originating on such other covered text providers' application services. Covered text providers using the CMRS network to deliver 911 text messages must clearly inform consumers that, absent an SMS plan with the consumer's underlying CMRS provider, the covered text provider may be unable to deliver 911 text messages.

CMRS providers may migrate to other technologies and need not retain SMS networks solely for other covered text providers' 911 use, but must notify the affected covered text providers not less than 90 days before the migration is to occur. We seek comment on adopting this or a comparable requirement here. We recognize that text-to-911 network integration is necessary to facilitate a CMRS network-based solution, and we seek comment on whether the same integration is necessary for transmission of text-to-988 communications by other covered text providers using that solution.

We seek comment on this proposal. Finally, as in the text-to-911 context, if we adopt a rule comparable to the text-to-911 rule above, we propose requiring 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 seek comment on this proposal.

38. We also seek comment on specific technical considerations for covered text providers that are rural or regional providers, or small businesses. Are there unique impediments or challenges to implementation that these types of providers face that warrant further consideration?.

39. Equipment Upgrades. We seek comment on possible equipment or software upgrades required for covered text providers to implement text-to-988.

What challenges will equipment (e.g., handsets, network infrastructure) and software vendors face with respect to the implementation and deployment of text-to-988?. For example, are upgrades required for operating systems, firmware, or other software on mobile devices to support text-to-988 capability?. Are there upgrades necessary by vendors that are beyond the covered text providers' control that require additional coordination?.

If the device's text messaging software can be upgraded over the air to support a text to 911, however, then the Commission required the covered text provider to make the necessary software upgrade available. Should we include a Start Printed Page 31411similar exemption for legacy devices under any text-to-988 requirements we may adopt?. Have circumstances changed in the past seven years such that we should adopt a different approach here?.

5. Cost Recovery 41. Consistent with the Commission's decision in the 988 Report and Order, we propose to require that all covered text providers bear their own costs to implement text-to-988 capability to the Lifeline 10-digit number.

As with call routing to 988, we do not anticipate any shared industry costs are necessary to implement text-to-988, in contrast to previous non-988 numbering proceedings where the Commission established a cost recovery mechanism. As proposed, costs to support text-to-988 would be borne by each provider, specific to the solutions each has adopted to route texts to 988 ultimately to the Lifeline's current toll free access number, presently 1-800-273-8255 (TALK). We seek comment on this proposal.

42. We believe this approach promotes efficiency in implementation and avoids unnecessary administrative costs. Section 251(e)(2) of the Act states 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 basis.â The Commission typically applies cost recovery mechanisms in situations involving some type of numbering administration arrangement, such as when the Commission hires a third party to develop a database for industry use, to ensure that the statutory cost neutrality requirements are met.

We seek comment on this analysis. 6. Bounce-Back Messages 43.

We seek comment on whether and in what circumstances to require covered text providers to send automatic bounce-back messages where text-to-988 service is unavailable. Throughout the ongoing roll-out of text-to-911 services across the U.S., the Commission has required covered text providers to send an automatic reply, or bounce-back, text message when a consumer attempts to send a text message to a PSAP by means of the 3-digit code â911â and the covered text provider cannot deliver the text because (1) the consumer is located in an area where text-to-911 is not available, or (2) the covered text provider either does not support text-to-911 generally or does not support it in the particular area at the time of the consumer's attempted text. Unlike in the text-to-911 context, where availability varies by geography and is based on whether the local PSAP can receive texts, our proposals herein would require covered text providers to support nationwide texting to the Lifeline via the 988 3-digit code on a uniform nationwide deadline.

If we were to adopt our proposal, should we nonetheless require bounce-back messages?. If so, when and under what circumstances?. Should we require covered text providers to make available bounce-back messages sooner than we require implementation of text-to-988?.

Would requiring bounce-back messages be appropriate if we adopt a uniform nationwide deadline for text-to-988 capability later than July 16, 2022âthe uniform nationwide deadline for covered providers to support calls to 988?. Would requiring bounce-back messages be appropriate if we adopt exemptions or extensions for some providers?. 44.

Because some individuals with disabilities may rely exclusively on texting for communicating, are there unique benefits of a bounce-back requirement for these individuals?. Since the Commission designated 988 as the 3-digit dialing code to access the Lifeline, efforts have been underway to educate the public about using this 3-digit code to reach help by telephone in times of mental health crisis, including its availability for routing voice calls to the Lifeline by July 16, 2022. In the absence of a bounce-back, might such advertising confuse the public about the availability of texting to 988?.

Would an automated bounce-back help to prevent such confusion?. Are there other advantages to requiring covered text providers to send bounce-back messages for attempts to text 988 where service is unavailable?. Are any providers included under the proposed âcovered text providersâ definition currently sending bounce-back messages to texts sent to 988?.

45. What are the costs of requiring a bounce-back message?. What work or upgrades would be necessary for text service providers to implement an automatic bounce-back reply?.

Given that covered text providers must provide a bounce-back in circumstances in which text-to-911 is unavailable, would adding a comparable bounce-back message for 988 be easier than if that existing infrastructure were not in place?. Would requiring text service providers to build bounce-back capabilities deter resources from more rapid deployment of text-to-988?. 46.

One commenter contends that if at-risk texters receive a bounce-back message regarding the unavailability of services, âthe risks of disengagement and adverse outcomes increase.â Do commenters agree with the assessment that an automatic bounce-back message will negatively impact individuals seeking help during a crisis?. Would a bounce-back message have the effect of making the sender more discouraged, such that it that could increase, not decrease, the likelihood of suicide?. Alternatively, if there is no automatic reply, and the sender is left wondering whether the Lifeline received the text message, would that uncertainty also increase sender's likelihood of suicide?.

We seek comment on whether the benefits of receiving an automatic bounce-back message outweigh the potential risk of disengagement. 47. If we were to adopt a bounce-back requirement, we seek comment on the specific requirement we should adopt.

To align with the scope of the proposed outer bound text-to-988 capability requirements, we propose that if we were to adopt a bounce-back requirement, we would require all covered text providers to provide automatic bounce-back messages to text messages, as defined by our outer bound Start Printed Page 31412proposal herein, sent to 988 where text-to-988 service is unavailable. We seek comment on this approach. Are there unique considerations for different technologies within the outer bound scope of text message that we should consider under our bounce-back message proposal, including such impact on technical implementation or costs?.

Should we consider requiring covered text providers to send automatic bounce-back messages in reply to messages outside the scope of the outer bound definition?. Are there additional text or chat service providers that offer services beyond the proposed outer bound definition that we should include within the scope of our proposed bounce-back requirement?. Should we limit any bounce-back requirement to covered text providers, as proposed, or should the requirement sweep more broadly?.

We seek comment on the impact including other text or chat service providers, or other forms of messages, may have on the implementation costs, technical feasibility, and timeframe for our proposed bounce-back message requirements. 48. Should we adopt a bounce-back requirement, we seek comment on whether and how to expand on the circumstances in which a covered text provider must provide a bounce-back message due to unavailability of text-to-988.

In the text-to-911 context, when a customer is roaming away from his or her âhome networkâ (i.e., the network of the customer's mobile carrier), the CMRS provider operating the customer's home network is nonetheless responsible for providing a bounce-back message when required. And the provider operating the network on which the customer is roaming must not impede the bounce-back response by the home network operator. We seek comment on adopting a similar requirement here.

Additionally, we anticipate that there may be circumstances in which the Lifeline is unable to receive and respond to texts, including where demand may exceed its capacity to respond. In instances amounting essentially to a âbusy signalâ for text delivery, are covered text providers capable of determining that the text cannot be delivered to 988?. Would covered text providers be able to determine if a text to 988 is undeliverable due to the Lifeline's inability, whether temporary or sustained, to receive and respond to the texts?.

Or should we establish a mechanism whereby the Lifeline may inform providers of a temporary suspension of text-to-988 service, and should the bounce-back requirement apply until the suspension is lifted?. Lastly, we seek comment on considerations, either within the control of the covered text provider or the Lifeline's administrators, in which a message from an individual in crisis attempting to reach 988 may not be delivered, and therefore may benefit from receipt of a bounce-back message directing the individual to contact 988 by alternative means. Are there additional circumstances where we should require covered text providers to send bounce-back messages in response to 988 texts?.

(1) Transmission of the text message is not controlled by the provider. (2) a consumer is attempting to text 988, through a text messaging application that requires CMRS service, from a non-service initialized handset. (3) the text-to-988 message cannot be delivered due to a failure in the Lifeline's routing network that has not been reported to the provider.

Or (4) a consumer is attempting to text 988 through a device that is incapable of sending texts via 3-digit codes, provided that the software for the device cannot be upgraded over the air to allow text-to-988. We seek comment on this approach. Are there other situations where a covered text provider should not be required to send bounce-back messages to consumers attempting to text to 988?.

Furthermore, we seek comment on the circumstances in which the provider of a pre-installed or downloaded interconnected text application would be considered to have âcontrolâ over the transmission of text messages for the purposes of any requirements we adopt. If a user or third party modifies or manipulates the application after it is installed or downloaded so that it no longer supports bounce-back messaging, should the application provider be presumed not to have control?. 50.

If we adopt a bounce-back requirement, should we specify or provide guidance regarding the content of the bounce-back message, and if so, what should we specify or encourage?. Similar to automatic messages sent in response to undeliverable texts to 911, we propose that any bounce-back messages to consumers attempting to text 988 would not require all covered text providers to use identical wording for their automatic responses. Rather, if we were to adopt a bounce-back requirement, we propose that a covered text provider would be deemed to have met its obligation so long as the bounce-back message to 988 includes, at a minimum, two essential points of information.

(1) That text-to-988 is not available. And (2) identify other means to reach the Lifeline, such as by telephone. We seek comment on this approach and on alternatives.

We seek comment on what role our federal partners and non-governmental mental health organizations could play in developing best practices regarding the content of messages. 7. Role of the Substance Abuse and Mental Health Services Administration and the Department of Veterans Affairs 51.

Although the Commission has an important role to play in expanding access to crisis counseling through its implementation of 988, SAMHSA and the VA are ultimately responsible for ensuring the continued success of these lifesaving resources. As such, we propose to direct the Bureau to continue to coordinate the implementation of 988 with SAMHSA and the VA, including any issues pertaining to the delivery of text messages to 988. 52.

We seek comment on this proposal. How we can best support the work of our federal partners in administering the Lifeline and Veterans Crisis Line?. We recognize that many commenters have stressed the importance of ensuring adequate funding and staffing for the Lifeline and the Veterans Crisis Line over the course of this proceeding.

Although these issues are beyond our jurisdiction, are there unique considerations pertaining to staffing, funding, or the availability of other resources at the Lifeline or Veterans Crisis Line that we should be aware of as we consider adopting rules to require the delivery of text messages to 988?. How should we account for the possibility that text-to-988 may be popular and increase demands on the Lifeline and Veterans Crisis Line?. What resources will be needed for the Lifeline and Veterans Crisis Line to ensure that text-to-988 is a success?.

Assuming that our adoption of rules implementing text-to-988 capability will require expenditure of additional resources by SAMHSA and the VA, are there ways that we can structure our rules to minimize the burden on our federal partners?. Are there any steps we should take to deter misuse of text-to-988, so as to limit the unnecessary expenditure of resources by our federal partners?. Are there any solutions that have been employed in other contexts, such as text-to-911, that we or others should adapt here to deter misuse of text-to-988?.

53. In addition, we encourage SAMHSA and the VA to coordinate with outside organizations that have expertise in providing crisis counseling via text message as they develop the infrastructure to receive and respond to text messages which may one day be delivered to the Lifeline and Veterans Crisis Line via 988. Many commenters in this proceeding have urged collaboration between private entities like the Trevor Project and federal agencies providing similar services.

We therefore seek comment on how to facilitate such coordination across federal agencies and the private sector, as we work towards our shared goal of ensuring that all Americans have ready access to mental health counseling and support services. C. Legal Authority 54.

We propose concluding that we have the authority to adopt the rules proposed and for which we seek comment in this further notice of proposed rulemaking under Title III of the Act and the Twenty-First Century Communications and Video Accessibility Act (CVAA). We seek comment on these and any other sources of authority available to us. In particular, we seek comment on whether, and if so, to what extent, our numbering authority under section 251(e) of the Act provides an additional source of authority for the rules proposed and for which we seek comment in this further notice of proposed rulemaking.

55. The rules we propose and for which we seek comment in this further notice of proposed rulemaking are analogous to those the Commission has adopted to facilitate text-to-911 communications, which relied, in part, on the Commission's Title III authority over wireless carriers, including sections 301, 303, 307, 309, and 316. We propose concluding that, with respect to CMRS providers, Title III provides us with appropriate authority to require wireless carriers to support text-to-988 service and to require delivery of a bounce-back message to consumers in cases where delivery of a text to 988 cannot be completed.

As the Supreme Court has long recognized, Title III grants the Commission a âcomprehensive mandateâ regarding regulation of spectrum usage, and courts have routinely found that Title III provides the Commission with âbroad authority to manage spectrum. . .

In the public interest.â As we explain, we believe the rules we propose in this further notice of proposed rulemaking are likely to have significant public interest benefits. And, the Commission has previously found that its Title III licensing authority supported adoption of a similar set of obligations in the text-to-911 context. Therefore, we believe that with respect to CMRS providers, Title III provides sufficient authority here.

We note that, following the release of the Text-to-911 Order, the Commission released a Declaratory Ruling classifying SMS and MMS services as âinformation servicesâ under the Act. However, as the Commission explicitly noted in the Declaratory Ruling, this determination âdoes not affect the general applicability of the spectrum allocation and licensing provisions of Title III and the Commission's rulesâ to SMS and MMS services, nor does it affect the specific application of sections 301, 303, 307, 309, and 316 to the Commission's text-to-911 rules. We seek comment on this analysis.

The CVAA provides the Commission with authority to âachiev[e] equal access to emergency services by individuals with disabilities, as a part of the migration to a national internet protocol-enabled emergency network.â In particular, the CVAA granted the Commission the authority to adopt regulations to implement recommendations proposed by the Emergency Access Advisory Committee established by the CVAA, which concern access to 911 and NG911 services, and to adopt âother regulationsâ as are necessary to achieve reliable, interoperable communication that ensures access by persons with disabilities to an IP-enabled emergency services network. We tentatively conclude that the CVAA provides authority for our proposals because access to 988 is similar to 911 access for the purposes of our CVAA authority. We seek comment on this tentative conclusion.

Do commenters agree that access to the Lifeline or Veterans Crisis Line through 988 constitute âaccess to emergency servicesâ under the CVAA?. Do commenters agree that text-to-988 is necessary to achieve reliable, interoperable communication that ensures access by persons with disabilities to an IP-enabled emergency services network?. More generally, does the CVAA provide us with authority to adopt the rules proposed in this further notice of proposed rulemaking?.

57. We seek comment on any other sources of authority available to the Commission to adopt the proposals detailed in this further notice of proposed rulemaking. In particular, we seek comment on whether our section 251(e) authority over numbering provides authority to require support for text-to-988 service.

Section 251(e)(1) of the Act grants us âexclusive jurisdiction over those portions of the North American Numbering Plan that pertain to the United Statesâ and provides that numbers must be made âavailable on an equitable basis.â This provision gives the Commission âauthority to set policy with respect to all facets of numbering administration in the United States.â The Commission found in the 988 Report and Order that section 251(e) provides us with the ability to regulate interconnected and one-way VoIP providers that make use of numbering resources when they connect with the PSTN. We seek comment on whether our numbering authority provides an additional, independent basis to adopt rules with respect to CMRS providers Start Printed Page 31414and interconnected text messaging services. 58.

Should we choose to require covered text providers to include location information with texts to 988, does section 222 authorize the disclosure of location information with texts to 988?. Are there other privacy concerns that we should consider with regard to texts to 988?. 59.

Finally, we seek comment on whether exercise of our ancillary authority would be necessary or appropriate to support any of our proposed rules. The Commission relied in part on ancillary authority to apply the bounce-back notification requirement to providers of interconnected text messaging services when it adopted text-to-911 requirements. Would a similar finding be appropriate with respect to any aspect of our text-to-988 rules?.

D. Benefits and Costs of Text-to-988 60. We expect to find that the benefits of requiring service providers to support text-to-988 service will exceed the costs of implementation.

We seek comment on this proposal, and any specific data regarding both the benefits of facilitating access to the Lifeline via texts to 988 and on the costs or burdens implementation of text-to-988 may impose upon covered text providers. 61. Suicide causes shock, anguish, grief, and guilt among victims' families and friends.

By expanding access to counseling, text-to-988 may help break the cycle of pain, suffering, and suicide. We seek comment generally on these and other important benefits that may follow from increased access to mental health resources via texting to 988. 62.

We further seek comment on ways to quantify these benefits. Of course, the benefits to individuals who the Lifeline or Veterans Crisis Line places on a path to recovery, much less to their families and friends, cannot be reduced to dollars and cents. That being said, even if text-to-988 service could annually place just one-per-one-thousand suicide victims on a path to long-term recovery, the economic gain would be $19.2 million in any single year, for a present-value of $78.7 million over five years and $134.9 million over ten years.

In estimating benefits, we focus on teens and individuals with disabilities, as individuals in these groups are more likely to use a text-to-988 capability. Based on the most recent CDC data from 2015-2019, 11,283 youth (ages 15-19) and an estimated 13,101 individuals who are deaf, hard of hearing, deafblind or speech disabled committed suicide (using an estimated incidence among adults of 6%), or an average of more than 2,000 per year for each group. To calculate the estimated benefits for a single year, we multiply the annual average by 0.1% and the VSL (2,000 * 0.001 * $9.6 million = $19.2 million).

We discount over five years and ten years at a 7% discount rate. We seek comment on this analysis. 63.

Moreover, we have not examined the benefits of text-to-988 usage by every demographic group. For example, smartphone ownership and suicide are particularly common in younger age groups. According to the Common Sense Census.

Media Use by Tweens and Teens, 2019, 53% of children have their own smartphone by age 11, and 69% have one at age 12. Currently, our estimated benefits analysis looks at youth ages 15-19. To accurately estimate these benefits, we seek comment on how broadly we should define youth who may text to 988.

Relatedly, there is the possibility that adults without hearing or speech disabilities may rely exclusively on text-to-988 for added privacy or convenience, meriting inclusion in our benefit estimates. We also seek comment on ways to better assess the long-term impact of text-to-988 service. Without longitudinal studies evaluating the long-term effectiveness of suicide call centers, we cannot pinpoint how many suicides text-to-988 will prevent in the long run.

Available survey-based studies, however, reveal call centers can substantially reduce suicides during the initial call and follow-up periods. We seek comment on the types and magnitudes of these and other benefits not covered in this further notice of proposed rulemaking, as well as any overlooked categories of costs. 64.

Interconnected text providers' software upgrades. And bounce-back messaging application alterations and server platform modifications. Assuming that all or most of the software and equipment necessary to receive and transmit 911 texts will again be needed to deploy text-to-988, we expect that the implementation costs for text-to-988 service will be comparable to the costs for text-to-911 service.

Using cost estimates from the Text-to-911 proceeding as a model, we estimate it will cost $19,024,916 for CMRS providers to implement text-to-988, $613,275 for interconnected text messaging service providers to implement text-to-988, and $7,310,340 for Lifeline to route texts to local crisis centers. We convert the estimate for CMRS providers to implement text-to-911 service to 2021 dollars by multiplying by a Consumer Price Index (CPI) factor of 1.16, then discounting over five years at a 7% discount rate. Similarly, we convert the estimate for interconnected text messaging providers to implement text-to-911 service into 2021 dollars by using a CPI factor of 1.105.

To soberly assess Lifeline capability, we assume that 100% of Lifeline call centers may require SMS upgrades and thus multiply PSAP software estimates by 2.22. To estimate the costs to equip the more than 180 Lifeline crisis centers, we calculate an average cost based on an estimated per PSAP cost of $40,613 (=($263,277,595 + $12,891,283)/6,800), for a total of $7,310,340 (=180 * $40,613). Therefore, we preliminarily estimate that total costs for implementing text-to-988 will be approximately $27 million.

We seek Start Printed Page 31415comment on this analysis, including our preliminary assumption that text-to-911 software and equipment can be leveraged for texting to 988. Do commenters agree with CTIA that there are âsignificant technical and policy differencesâ between 988 and 911 service, and if so, how might those differences impact our evaluation?. Furthermore, we seek comment on whether cost estimates for PSAPs from the Text-to-911 proceeding reflect an appropriate estimate for costs to the Lifeline or Veterans Crisis Line.

As a result, we anticipate that costs for covered text providers to implement text-to-988 may be less than what we estimate above and seek comment on this finding. We further seek comment on what extent covered text providers may rely upon existing text-to-911 services and how to quantify the costs needed to upgrade such systems to support text-to-988. 66.

Deterring suicide has benefits that simply cannot be reduced to numbersâsaving lives has value beyond measure. While recognizing this fact, to illustrate how the benefits of our proposal relate to the more aptly quantified costs, we attempt to estimate the quantifiable value of suicide prevention using a measure of collective willingness to pay. We propose calculating that the level of suicide prevention needed to generate benefits exceeding our preliminary estimate of $27 million in text-to-988 costs is a total of four suicides avoided over five years.

Specifically, the level of teen suicide prevention needed to generate benefits exceeding $27 million is one per 2,821, and the level of suicide prevention among individuals with disabilities to generate benefits exceeding $27 million is one per 3,275. Even assuming that text-to-988 prevented no suicides in its inaugural year as the service rolled out but prevented one suicide in each of the ensuing four years, measured in terms of the public's willingness to pay for that mortality reduction, the present value of the benefit would be $30.39 million, more than three million dollars greater than the total cost. The present value would be an uneven stream of payments of $9.6 million ($0 in Year 1 + $9.6 million per year in Year 2 through Year 5) at a 7% discount rate.

We seek comment on our analysis. 67. Using break-even points and highly attainable suicide reductions that are well below those suggested by survey studies, we estimate that the benefits of text-to-988 will far exceed the costs.

Over ten years, the benefits rise to $269.8 million, exceeding costs by a multiple of nearly ten. We seek comment on these estimates. We also seek comment on the methods and underlying benefits and costs estimates, including those submitted by third parties, used to arrive at our overall proposed conclusion.

II. Initial Regulatory Flexibility Analysis 1. As required by the Regulatory Flexibility Act of 1980, as amended (RFA), the Commission has prepared this Initial Regulatory Flexibility Analysis (IRFA) of the possible significant economic impact on small entities by the policies and rules proposed in this Implementation of the National Suicide Hotline Improvement Act of 2018 further notice of proposed rulemaking (FNPRM).

The Commission requests written public comments on this IRFA. Comments must be identified as responses to the IRFA and must be filed by the deadlines for comments provided on the first page of the further notice of proposed rulemaking. The Commission will send a copy of the further notice of proposed rulemaking, including this IRFA, to the Chief Counsel for Advocacy of the Small Business Administration (SBA).

In addition, the further notice of proposed rulemaking and IRFA (or summaries thereof) will be published in the Federal Register. A. Need for, and Objectives of, the Proposed Rules 2.

B. Legal Basis 3. The legal basis for any action that may be taken pursuant to this FNPRM is contained in sections 201, 251, 301, 303, 307, 309, and 316 of the Communications Act of 1934, as amended, 47 U.S.C.

201, 251, 301, 303, 307, 309, 316. C. Description and Estimate of the Number of Small Entities to Which the Proposed Rules Will Apply 4.

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 proposed rules and by the rule revisions on which the Notice seeks comment, if adopted. 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.

5. 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 Small Business Administration's (SBA) 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 Start Printed Page 31416States, which translates to 30.7 million businesses.

6. 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. 7. 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 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 50,000. Accordingly, based on the 2017 U.S.

Census of Governments data, we estimate that at least 48,971 entities fall into the category of âsmall governmental jurisdictions.â 8. 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 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. 9.

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 NAICS Code category is Wired Telecommunications Carriers.

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. 10.

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. 11.

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.

We have included small incumbent LECs in this present RFA analysis. As noted above, a âsmall businessâ under the RFA is one that, inter alia, meets the pertinent small business size standard (e.g., a telephone communications business having 1,500 or fewer employees), and âis not dominant in its field of operation.â The SBA's Office of Advocacy contends that, for RFA purposes, small incumbent LECs are not dominant in their field of operation because any such dominance is not ânationalâ in scope. We have therefore included small incumbent LECs in this RFA analysis, although we emphasize that this RFA action has no effect on Commission analyses and determinations in other, non-RFA contexts.

13. 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.

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.

15. Toll Resellers. The Commission has not developed a definition for Toll Resellers.

The closest NAICS Code Category is Telecommunications 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 this total, an estimated 857 have 1,500 or fewer employees. Consequently, the Commission estimates that the majority of toll resellers are small entities. 16.

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.

17. 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. Mobile virtual networks operators (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.

18. Wireless Telecommunications Carriers (except Satellite). Neither the SBA nor the Commission has developed a size standard specifically applicable to Wireless Carriers and Service Providers.

The closest applicable is Wireless Telecommunications Carriers (except Satellite), which the SBA small business size standard is such a business is small if it 1,500 persons or less. 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 had employment of 999 or fewer employees and 12 had employment of 1000 employees or more. Thus under this category and the associated size standard, the Commission estimates that the majority of Wireless Carriers and Service Providers are small entities. 19.

According to internally developed Commission data for all classes of Wireless Service Providers, there are 970 carriers that reported they were engaged in the provision of wireless services. Of this total, an estimated 815 have 1,500 or fewer employees, and 155 have more than 1,500 employees. Thus, using available data, we estimate that the majority of Wireless Carriers and Service Providers can be considered small.

20. 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 Start Printed Page 31418systems, for transmission to viewers.â 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. 21.

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.

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 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.

22. 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. 23. All Other Telecommunications.

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. 24.

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, 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 or fewer employees. U.S.

25. 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.

26. Software Publishers. This industry comprises establishments primarily engaged in computer software publishing or publishing and reproduction.

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. 27. Internet Service Providers (Broadband).

Broadband internet service providers include wired (e.g., cable, 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 Start Printed Page 31419that 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. 28.

Internet Service Providers (Non-Broadband). Internet access service providers such as Dial-up internet service providers, 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. 29. 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 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.

D. Description of Projected Reporting, Recordkeeping, and Other Compliance Requirements for Small Entities 30. The FNPRM proposes and seeks comment on rules to require covered text providers to support text messaging to 988.

It tentatively concludes that text-to-988 functionality will greatly improve consumer access to the Lifeline, particularly for at-risk populations, and thereby save lives. The proposed rules would 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 FNPRM proposes (1) establishing a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support.

And (2) directing 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. The FNPRM seeks comment on this proposal. The Commission preliminarily believes that applying the same rules equally to all entities in this context is necessary to alleviate potential consumer confusion from adopting different rules for different covered text providers.

The Commission proposes that the costs and/or administrative burdens associated with the rules will not unduly burden small entities. E. Steps Taken To Minimize the Significant Economic Impact on Small Entities, and Significant Alternatives Considered 31.

(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. 32.

In the FNPRM, the Commission seeks comment from all entities, including small entities, regarding the impact of these proposed rules on small entities. The Commission seeks comment on the impact, cost or otherwise, that requiring text messaging to 988 capability will impose on regional and rural carriers and small businesses. The Commission also seeks comment on whether to adopt any exemptions for small businesses and if so, under what circumstances.

The Commission asks and will consider alternatives to the proposals and on alternative ways of implementing the proposals. F. Federal Rules That May Duplicate, Overlap, or Conflict With the Proposed Rules 33.

Persons making oral ex parte presentations are reminded that memoranda summarizing the presentation must (1) list all persons attending or otherwise participating in the meeting at which the ex parte presentation was made, and (2) summarize all data presented and arguments made during the presentation. If the presentation consisted in whole or in part of the presentation of data or arguments already reflected in the presenter's written comments, memoranda or other filings in the proceeding, the presenter may provide citations to such data or arguments in his or her prior comments, memoranda, or other filings (specifying the relevant page and/or paragraph numbers where such data or arguments can be found) in lieu of summarizing them in the memorandum. Documents shown or given to Commission staff during ex parte meetings are deemed to be written ex parte presentations and must be filed consistent with Rule 1.1206(b).

In proceedings governed by Rule 1.49(f) or for which the Commission has made available a method of electronic filing, written ex parte presentations and memoranda summarizing oral ex parte presentations, and all attachments thereto, must be filed through the electronic comment filing system available for that proceeding, and must be filed in their native format (e.g., .doc, .xml, .ppt, searchable .pdf). Participants in this proceeding should familiarize themselves with the Commission's ex parte rules. 35.

Initial Regulatory Flexibility Analysis. Pursuant to the Regulatory Flexibility Act (RFA), the Commission has prepared an Initial Regulatory Flexibility Analysis (IRFA) of the possible significant economic impact on small entities of the policies and actions considered in this FNPRM. Written public comments are requested on this IRFA.

Comments must be identified as responses to the IRFA and must be filed by the deadlines for comments on the FNPRM. The Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, will send a copy of the FNPRM, including the IRFA, to the Chief Counsel for Advocacy of the Small Business Administration.Start Printed Page 31420 36. Comment Filing Procedures.

Electronic Filers. Comments may be filed electronically using the internet by accessing ECFS. Https://www.fcc.gov/âecfs/â.

Paper Filers. Parties who choose to file by paper must file an original and one copy of each filing. Filings can be sent by commercial overnight courier, or by first-class or overnight U.S.

Postal Service mail. All filings must be addressed to the Commission's Secretary, Office of the Secretary, Federal Communications Commission. Commercial overnight mail (other than U.S.

Postal Service Express Mail and Priority Mail) must be sent to 9050 Junction Drive, Annapolis Junction, MD 20701. U.S. Postal Service first-class, Express, and Priority mail must be addressed to 45 L Street NE, Washington, DC 20554.

37. 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). 38. Paperwork Reduction Act of 1995 Analysis.

This document may contain proposed new or modified information collection requirements. The Commission, as part of its continuing effort to reduce paperwork burdens, invites the general public and the Office of Management and Budget (OMB) to comment on the information collection requirements contained in this document, as required by the Paperwork Reduction Act of 1995, Public Law 104-13. In addition, pursuant to the Small Business Paperwork Relief Act of 2002, Public Law 107-198, we seek specific comment on how we might further reduce the information collection burden for small business concerns with fewer than 25 employees.

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. It is ordered, pursuant to sections 201, 251, 301, 303, 307, 309, and 316 of the Communications Act of 1934, as amended, 47 U.S.C.

201, 251, 301, 303, 307, 309, 316, that the FNPRM in WC Docket No. 18-336 is adopted. 41.

It is further ordered that the Petition for Reconsideration filed by Communications Equality Advocates is granted in part to the extent described herein. 42. It is further ordered that the Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, shall send a copy of this FNPRM, including the Initial Regulatory Flexibility Analysis, to the Chief Counsel for Advocacy of the Small Business Administration.

Start List of Subjects Communications common carriersTelecommunicationsTelephone End List of Subjects Start Signature Federal Communications Commission. Marlene Dortch, Secretary. End Signature Proposed Rules For the reasons discussed in the preamble, the Federal Communications Commission proposes to amend 47 CFR part 52 as follows.

Start Part End Part Start Amendment Part1. The authority citation for part 52 is revised 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, 301, 303, 307, 309, 316, 332, unless otherwise noted. End Authority Start Amendment Part2. Add Â§â52.201 to subpart E 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 [[DATE]], all covered text providers must have the capability to 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) 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 a SMS message and a 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)(2) 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 shall mean all Commercial Mobile Radio Services (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. Multimedia message service (MMS) shall have the same definition as the term in Â§â64.1600(k) of the Commission's rules. Short message service (SMS) shall have the same definition as the term in Â§â64.1600(m) of the Commission's rules.

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The ISMICC is open to the public and members of the public can attend the meeting via black viagra pill telephone or webcast only, and not in special info person. Agenda with call-in information will be posted on SAMHSA's website prior to the meeting at. Https://www.samhsa.gov/âabout-us/âadvisory-councils/âmeetings. The meeting will include information on federal efforts related to serious mental illness (SMI) and black viagra pill serious emotional disturbance (SED). September 29, 2020, 1:00 p.m.âTBD (ET)/Open.

The meeting will be held at SAMHSA Headquarters, 5600 Fishers Lane, Rockville, Maryland 20857, Pavilions A and B. The meeting can be accessed via webcast black viagra pill at. Https://protect2.fireeye.com/âurl?. Âk=â766a2ec8-2a3f2718-766a1ff7-0cc47a6a52de-658aca2b78455d15&âu=â https://www.mymeetings.com/ânc/âjoin.php?. Âi=âPWXW1647116&âp=â4987834&ât=âc or by joining the teleconference at the black viagra pill toll-free, dial-in number at 877-950-3592.

Passcode 4987834. Start Further Info Pamela Foote, ISMICC Designated Federal Officer, SAMHSA, 5600 Fishers Lane, 14E53C, Rockville, MD 20857. Telephone. 240-276-1279. Email.

Pamela.foote@samhsa.hhs.gov. End Further Info End Preamble Start Supplemental Information I. Background and Authority The ISMICC was established on March 15, 2017, in accordance with section 6031 of the 21st Century Cures Act, and the Federal Advisory Committee Act, 5 U.S.C. App., as amended, to report to the Secretary, Congress, and any other relevant federal department or agency on advances in SMI and SED, research related to the prevention of, diagnosis of, intervention in, and treatment and recovery of SMIs, SEDs, and advances in access to services and supports for adults with SMI or children with SED. In addition, the ISMICC will evaluate the effect federal programs related to SMI and SED have on public health, including public health outcomes such as.

(A) Rates of suicide, suicide attempts, incidence and prevalence of SMIs, SEDs, and substance use disorders, overdose, overdose deaths, emergency hospitalizations, emergency room boarding, preventable emergency room visits, interaction with the criminal justice system, homelessness, and unemployment. (B) increased rates of employment and enrollment in educational and vocational programs. (C) quality of mental and substance use disorders treatment services. Or (D) any other criteria determined by the Secretary. Finally, the ISMICC will make specific recommendations for actions that agencies can take to better coordinate the administration of mental health services for adults with SMI or children with SED.

Not later than one (1) year after the date of enactment of the 21st Century Cures Act, and five (5) years after such date of enactment, the ISMICC shall submit a report to Congress and any other relevant federal department or agency. II. Membership This ISMICC consists of federal members listed below or their designees, and non-federal public members. Federal Membership. Members include, The Secretary of Health and Human Services.

The Assistant Secretary for Mental Health and Substance Use. The Attorney General. The Secretary of the Department of Veterans Affairs. The Secretary of the Department of Defense. The Secretary of the Department of Housing and Urban Development.

The Secretary of the Department of Education. The Secretary of the Department of Labor. The Administrator of the Centers for Medicare and Medicaid Services. And The Commissioner of the Social Security Administration. Non-Federal Membership.

Members include, 14 non-federal public members appointed by the Secretary, representing psychologists, psychiatrists, social workers, peer support specialists, and other providers, patients, family of patients, law enforcement, the judiciary, and leading research, advocacy, or service organizations. The ISMICC is required to meet at least twice per year. To attend virtually, submit written or brief oral comments, or request special accommodation for persons with disabilities, contact Pamela Foote. Individuals can also register on-line at. Https://snacregister.samhsa.gov/âMeetingList.aspx.

The public comment section is scheduled for 2:15 p.m. Eastern Time (ET), and individuals interested in submitting a comment, must notify Pamela Foote on or before September 18, 2020 via email to. Pamela.Foote@samhsa.hhs.gov. Up to three minutes will be allotted for each approved public comment as time permits. Written comments received in advance of the meeting will be considered for inclusion in the official record of the meeting.

Substantive meeting information and a roster of Committee members is available at the Committee's website. Https://www.samhsa.gov/âabout-us/âadvisory-councils/âmeetings. Start Signature Dated. September 1, 2020. Carlos Castillo, Committee Management Officer.

End Signature End Supplemental Information [FR Doc.

Notice Where can i purchase zithromax low price viagra. The Secretary of Health and Human Services announces a meeting of the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC). The ISMICC is open to the public and members of the public can attend the meeting via telephone or webcast only, and not in person.

Agenda with call-in information will be posted on SAMHSA's website prior to the meeting low price viagra at. Https://www.samhsa.gov/âabout-us/âadvisory-councils/âmeetings. The meeting will include information on federal efforts related to serious mental illness (SMI) and serious emotional disturbance (SED).

September 29, low price viagra 2020, 1:00 p.m.âTBD (ET)/Open. The meeting will be held at SAMHSA Headquarters, 5600 Fishers Lane, Rockville, Maryland 20857, Pavilions A and B. The meeting can be accessed via webcast at.

Https://protect2.fireeye.com/âurl?. Âk=â766a2ec8-2a3f2718-766a1ff7-0cc47a6a52de-658aca2b78455d15&âu=â https://www.mymeetings.com/ânc/âjoin.php?. Âi=âPWXW1647116&âp=â4987834&ât=âc or by joining the teleconference at the toll-free, dial-in number at 877-950-3592.

Passcode 4987834. Start Further Info Pamela Foote, ISMICC Designated Federal Officer, SAMHSA, 5600 Fishers Lane, 14E53C, Rockville, MD 20857. Telephone.

240-276-1279. Email. Pamela.foote@samhsa.hhs.gov.

End Further Info End Preamble Start Supplemental Information I. Background and Authority The ISMICC was established on March 15, 2017, in accordance with section 6031 of the 21st Century Cures Act, and the Federal Advisory Committee Act, 5 U.S.C. App., as amended, to report to the Secretary, Congress, and any other relevant federal department or agency on advances in SMI and SED, research related to the prevention of, diagnosis of, intervention in, and treatment and recovery of SMIs, SEDs, and advances in access to services and supports for adults with SMI or children with SED.

In addition, the ISMICC will evaluate the effect federal programs related to SMI and SED have on public health, including public health outcomes such as. (A) Rates of suicide, suicide attempts, incidence and prevalence of SMIs, SEDs, and substance use disorders, overdose, overdose deaths, emergency hospitalizations, emergency room boarding, preventable emergency room visits, interaction with the criminal justice system, homelessness, and unemployment. (B) increased rates of employment and enrollment in educational and vocational programs.

(C) quality of mental and substance use disorders treatment services. Or (D) any other criteria determined by the Secretary. Finally, the ISMICC will make specific recommendations for actions that agencies can take to better coordinate the administration of mental health services for adults with SMI or children with SED.

Federal Membership. Members include, The Secretary of Health and Human Services. The Assistant Secretary for Mental Health and Substance Use.

The Attorney General. The Secretary of the Department of Veterans Affairs. The Secretary of the Department of Defense.

The Secretary of the Department of Housing and Urban Development. The Secretary of the Department of Education. The Secretary of the Department of Labor.

The Administrator of the Centers for Medicare and Medicaid Services. And The Commissioner of the Social Security Administration. Non-Federal Membership.

Individuals can also register on-line at. Https://snacregister.samhsa.gov/âMeetingList.aspx. The public comment section is scheduled for 2:15 p.m.

Eastern Time (ET), and individuals interested in submitting a comment, must notify Pamela Foote on or before September 18, 2020 via email to. Pamela.Foote@samhsa.hhs.gov. Up to three minutes will be allotted for each approved public comment as time permits.

Written comments received in advance of the meeting will be considered for inclusion in the official record of the meeting. Substantive meeting information and a roster of Committee members is available at the Committee's website. Https://www.samhsa.gov/âabout-us/âadvisory-councils/âmeetings.