Information Collection

Universal Service - Rural Health Care Program

IC 199666 under ICR 201409-3060-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

IC Title:

Universal Service - Rural Health Care Program

Agency IC Tracking Number:

WCB

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 47 CFR 54.600 - 54.680

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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
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

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	18,015	18,015
Annual IC Time Burden (Hours)	21,847	21,847
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.