Information Collection

Universal Service - Rural Health Care Program

IC 199666 under ICR 201306-3060-006 · OMB 3060-0804.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-0804 can be found here:

Documents and Forms

Document Name Document Type
0804_Attachment 9 - Certification of Program Participant Template_062813.doc Other-Template
0804_Attachment 10 - Vendor Certification Template_062813.doc Other-Template
0804_Attachment 12_FCC Form 460 Instructions_062813.docx Instruction
0804_Attachment 14_FCC Form 461 Instructions_062813.docx Instruction
0804_Attachment 15_FCC Form 462 Instructions_062813.docx Instruction
FCC Form 460 Eligibility and Registration Form 0804_Attachment 11_FCC Form 460_062813.pdf Form
FCC Form 461 Healthcare Connect Fund Request for Services Form 0804_Attachment 13_FCC Form 461_062813.pdf Form
FCC Form 462 Healthcare Conect Fund Funding Request Form 0804_Attachment 16_FCC Form 462 with NCW_062813.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Universal Service - Rural Health Care Program	Agency IC Tracking Number:	WCB

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 47 CFR 54.601 - 54.625

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Template			0804_Attachment 9 - Certification of Program Participant Template_062813.doc	Yes	Yes	Fillable Fileable Signable
Other-Template			0804_Attachment 10 - Vendor Certification Template_062813.doc	Yes	Yes	Fillable Fileable Signable
Form	FCC Form 460	Eligibility and Registration Form	0804_Attachment 11_FCC Form 460_062813.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			0804_Attachment 12_FCC Form 460 Instructions_062813.docx	Yes	Yes	Fillable Fileable Signable
Form	FCC Form 461	Healthcare Connect Fund Request for Services Form	0804_Attachment 13_FCC Form 461_062813.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			0804_Attachment 14_FCC Form 461 Instructions_062813.docx	Yes	Yes	Fillable Fileable Signable
Instruction			0804_Attachment 15_FCC Form 462 Instructions_062813.docx	Yes	Yes	Fillable Fileable Signable
Form	FCC Form 462	Healthcare Conect Fund Funding Request Form	0804_Attachment 16_FCC Form 462 with NCW_062813.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,667	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	18,015	-6,432	24,447
Annual IC Time Burden (Hours)	21,847	-7,051	28,898
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.