SAMPLE FORM

General Information

Call Sign:

Channel Number:

Facility ID:

Community of License:

City:

State:

Zip Code:

Legal Name of Licensee:

Link to Online Public File:

Network Affiliation:

if none, please list as "independent"

Nielsen DMA:

Commercial / Non-Commercial:

Contact Name:

Contact Phone:

Link to most recent Form 323 (Ownership report):

Link to most recent Form 398 (Quarterly Children’s Television Report):

Programs

Program Reporting 1

Type of Reporting:

Composite Week

Election Period

Optional

Close Captioning Exempted Programming

Program / Segment Title / Topic:

Channel Number Aired:

Primary / Multicast:

Initial / Repeat:

Sponsor:

Is the material reported, or any portion of it subject to the disclosure requirements of the FCC sponsorship identification rule?

Agreements:

Was the material reported, or any portion of it, the product of a local marketing agreement, local news service, or shared service agreement, or any other contractual arrangement or agreement between the licensee and another broadcast station and/or daily newspaper located within the licensee’s designated market area?

Date and Time

Approximate length of program/segment excluding interstitial commercials, in minutes:

Please report the total number of complaints in the previous quarter with regard to its emergency programming that was not accessible to people with disabilities:

Total Programming Hours: