Form FCC Form 560 FCC Form 560 Low Income Broadband Pilot Program Reporting Form

Approved by OMB

3060-0819

FCC Form 560

November 2012

LOW INCOME BROADBAND PILOT PROGRAM REPORTING FORM

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS

The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. If we believe there may be a violation or a potential violation of a FCC statute, regulation, rule or order, your certification may be referred to the Federal, state or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In certain cases, the information in your certification may be disclosed to the Department of Justice or a court or adjudicative body when a) the FCC; or b) any employee of the FCC; or c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding.

We have estimated that this collection of information will take .5 hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, Office of Managing Director, AMD‑PERM, Washington, DC 20554, Paperwork Reduction Act Project (3060‑0819). We will also accept your PRA comments if you send an e-mail to [email protected].

Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number and/or we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060‑0819.

THIS NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. SECTION 552a(e)(3) AND THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

COMPANY INFORMATION PROVIDED BY ETC WITH EACH SUBMISSION TO USAC

BLOCK A

Each ETC is required to submit the company specific information contained in block "Identifying Information - Block A" for each submission to USAC. All raw data that the ETC submits may be submitted as an Excel or CSV file.
Block A	Question	Response	Notes
Identifying Information	Service Provider Identification Number (SPIN)
	Study Area Code(s) (SAC)
	FCC Registration Number (FRN)
	Legal Company Name and d/b/a
	Company Mailing Address
	Company Telephone Number
	Company Fax number
	Company Contact Email Address
	Reporting Date
	Company Contact Name
	List of Project Code Identifiers in Pilot Project		Each variation of a proposed broadband service offering that an ETC offers in its project will be assigned a separate project code identifier by USAC (Project Code Identifier).

PROJECT-LEVEL INFORMATION PROVIDED BY ETC

BLOCK B

Each ETC is required to submit information contained in block "Broadband Service Offering Information - Block B" to USAC once, at the beginning of the ETC's project for each Project Code Identifier.
Block B	Question	Response	Notes
Broadband Service Offering Information	Project Code Identifier		Identifies the study group in terms of discount plans
	List of geographic areas (e.g., census tract, wire center, study area) receiving this variation of the broadband service offering		Identifies relevant geographies being treated in study
	Zip Codes receiving this variation of broadband service offering		List all zip codes fully or partially in this variation of broadband offering

PROJECT-LEVEL INFORMATION PROVIDED BY ETC

BLOCK C

Each ETC is required to submit information contained in block "Project Information - Block C," to USAC once, at the beginning of the ETC's project for each Project Code Identifier.
Block C	Question	Response	Notes
Project Information	Maximum number of months discount is available	0 - 12	Number of months discount is offered in study
	Type of service offering	Bundled Voice & BB; Stand-alone BB
	Technology used	Mobile, Fixed-wireless, Wireline (Telco or Cable), Other (indicate)
	Broadband speed provided	specify upload and download speed	Provide advertised speeds.
	Monthly usage limit, if any	GB/month	If usage limits do not apply, respond with N/A.
	If monthly usage limit applies, whether overage charges apply and if so, specify rate amount	$	If usage limits do not apply, respond with N/A. If overage charges do not apply, respond with N/A
	If monthly usage limit applies with no overage charges, specify whether service is discontinued or broadband speed is reduced	Discontinued service, broadband speed is reduced, none of the above (specify)	If usage limits do not apply, respond with N/A. If overage charges apply for exceeding usage limits, respond with N/A.
	Monthly broadband discount amount	$
	Monthly cost to subscriber for broadband service after discount	$
	Amount of discount provided to reduce or eliminate non-recurring fee(s), if any	$
	Amount of non-recurring fees, if any, charged to subscriber after discount	$
	Amount of discount for equipment provided to subscriber by ETC, if any	$	If subscriber receives equipment at no cost, please include value of equipment given to subscriber
	Cost to subscriber of equipment provided by ETC that is used for broadband after discount	$
	Digital literacy training offered as part of broadband service offering	Yes/No

PROJECT-LEVEL INFORMATION PROVIDED BY ETC

BLOCK D

Each ETC is required to submit information contained in block "Aggregate Population Information for Variations of Broadband Service Offering - Block D" to USAC on a quarterly basis for each Project Code Identifier. If necessary provide a best estimate.
Block D	Question	Response	Notes
Aggregate Population Information for Variation of Broadband Service Offering	Project Code Identifier		Identifies the study group in terms of discount plans
	Total number of Lifeline eligible subscribers in study population		Estimate if necessary, explaining your assumptions
	Total number of eligible subscribers offered this variation of broadband service during the pilot		Estimate if necessary, explaining your assumptions
	Total number of subscribers enrolled in the offered discount during the first month of the quarter
	Total number of subscribers enrolled in the discount during the second month of the quarter
	Total number of subscribers enrolled in the offered discount during the third month of the quarter
	Total number of subscribers that have de-enrolled in the offered discount during the first month of the quarter
	Total number of subscribers that have de-enrolled in the offered discount during the second month of the quarter
	Total number of subscribers that have de-enrolled in the offered discount during third month of the quarter

SUBSCRIBER-LEVEL INFORMATION PROVIDED BY ETC

BLOCK E

Each ETC is required to submit the information contained in block "Enrollment Information - Block E" to USAC when all subscribers have enrolled in the ETC's project. Each subscriber must have a unique identifier, which will be used throughout the study, assigned by the ETC (Unique Subscriber Identifier).
Block E	Question	Response	Notes
Enrollment Information	Unique Subscriber Identifier		Unique, anonymized identifier assigned by ETC	Provided by ETC
	Project Code Identifier		Identifies the subscriber's study group in terms of discount plan
	Geographic Area
	Zip code(s)
	Date Subscribed	MM/DD/YY
	Digital Literacy Program Offered?	Yes/No
	Digital Literacy Offer Accepted at Enrollment?	Yes/No	Only enter if literacy program is offered to subscriber

SUBSCRIBER-LEVEL INFORMATION PROVIDED BY ETC

BLOCK F

Each ETC is required to submit the information contained in block "Follow-Up and Retention Information – Block F" based on subscriber records within three months after the subscriber received the last discount in the pilot. Each subscriber must have a unique identifier, which will be used throughout the study, assigned by the ETC (Unique Subscriber Identifier).
Block F	Question	Response	Notes
Follow-Up and Retention Information	Unique Subscriber Identifier		Unique, anonymized identifier assigned by the ETC	Provided by ETC
	Project Code Identifier		Identifies the subscriber's study group in terms of discount plan
	Did the subscriber participate in the study for the full duration of the program?	Yes/No
	Number of months of discount actually received	0-12
	If not currently subscribing, date service ended	MM/DD/YY	If customer ended service, indicate date ended
	Did subscriber retain service with the ETC in the first month following the last discount (i.e. the first unsubsidized month)?	Yes/No
	Did subscriber retain service with the ETC in the second month following the last discount (i.e. the second unsubsidized month)?	Yes/No
	Did subscriber retain service with the ETC in the third month following the last discount (i.e. the third unsubsidized month)?	Yes/No

SUBSCRIBER-LEVEL INFORMATION COLLECTED FROM THE SUBSCRIBER

BLOCK G

Each ETC, or USAC if the ETC requests, is required to collect the information contained in block "Subscriber-Provided Information at Enrollment – Block G" directly from each subscriber prior to providing a discount and submit when all subscribers have enrolled in the project. ETCs have the option of having USAC collect this information through an electronic, online survey at enrollment; subscribers must consent to collection and sharing of this information in order to receive any discount. Each subscriber must have a unique identifier, which will be used throughout the study, assigned by the ETC (Unique Subscriber Identifier).
Block G	Question	Response	Notes
Subscriber-Provided Information at Enrollment				Collected from Subscriber
	Unique Subscriber Identifier		Unique, anonymized identifier assigned by the ETC
	Project Code Identifier		Identifies the subscriber's study group in terms of discount plan
	Subscriber Age
	Ages of household members
	Number of household members using subsidized broadband
	In 2011, what was this household's total income before taxes?	Less than $5,000, $5000-$9999 $10,000-$20,000, $20,001-$30,000, $30,001 or more, Not Determined
	Equipment expected to be used with broadband service - choose multiple	Desktop Computer, Laptop/netbook computer, Tablet, Mobile device (smartphone), mobile broadband modem (aircard)
	Has this consumer subscribed to broadband in the past?	Never, Within last 3 months, Within last 6 months, Within last 12 months, More than 12 months ago
	Reasons for not previously obtaining broadband - can choose more than one	Monthly cost too expensive, didn't use service, don't know how to use computer/Internet, uncomfortable with Internet (e.g. privacy concerns, dangerous for children), happy with dial-up, could access Internet elsewhere, other – specify
	If subscriber previously subscribed to broadband, but dropped service, reason for dropping (can choose more than one response)	Monthly cost too expensive, didn't use service, the equipment no longer worked, don't know how to use computer/Internet, uncomfortable with Internet (e.g. privacy concerns, dangerous for children), happy with dial-up, could access Internet elsewhere	Answer NA if previous answer is "Never"
	Reason(s) for use of Internet (can choose more than one response)	Want to stay in touch with family and friends, children need it for school, subscriber needs it for school, want to access music, movies and other entertainment, children want internet access, get health care or medical information, job required online access, need it for job searches, want to share photos or videos with family and friends, internet provider offered a good price for the service, use for daily activities (e.g. check bus schedule), other --- specify

SUBSCRIBER-LEVEL INFORMATION COLLECTED FROM THE SUBSCRIBER

BLOCK H

Each ETC, or USAC if the ETC requests, must collect the information contained in block “Follow-up and Subscriber Usage Information – Block H” from the subscriber no later than the end of the project. ETCs have the option of having USAC collect this information through an electronic, online survey; subscribers must consent to collection and sharing of this information in order to continue receiving any discounted broadband service. Each subscriber must have a unique identifier, which will be used throughout the study, assigned by the ETC (Unique Subscriber Identifier).
Block H	Question	Response	Notes
Follow-Up and Subscriber-Usage Information	Unique Subscriber Identifier		Unique, anonymized identifier assigned by the ETC	Collected from Subscriber
	Project Code Identifier		Identifies the subscriber's study group in terms of discount plan
	Number of Household members using discounted broadband service
	Subscriber use of Internet (can choose more than one response)	Want to stay in touch with family and friends, children need it for school, subscriber needs it for school, want to access music, movies and other entertainment, children want internet access, job required online access, need it for job searches, want to share photos or videos with family and friends, internet provider offered a good price for the service, use for daily activities (paying bills), other --- specify
	Did the subscriber participate or is currently participating in any training programs so he/she can better use a computer and the Internet?	No training class taken, currently taking a training class, completed a training class
	Equipment used with service (can choose more than one response)	Desktop Computer, Laptop Computer (includes netbook), Tablet, Mobile Device (Smartphone) Mobile Broadband Modem (aircard)

12