Information Collection

Universal Service - Rural Health Care Program

IC 31049 under ICR 201606-3060-028 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Attachment 2 - RHCPP-Sample-Project-Coordinator-Certification.doc	Other-Certification
Attachment 3 - RHCPP-Sample-Vendor-Certification.doc	Other-Vendor Certification
Attachment 5 - RHC CMHC-Certification-Checklist.pdf	Other-Certification Checklist
Copy of Attachment 1 - Copy of Network Cost Worksheet Excel Template.xls	Other-Excel Template
Copy of Attachment 4 - Copy of RHC Pilot Program_Invoice Template.xlsm	Other-Invoice Template
Copy of Attachment 6 - Copy of RHC Telecom Program_Invoice Template.xls	Other-Invoice Template
CMHC-Certification-Checklist.pdf	Other-Certification Checklist

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 54.600 - 54.680

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Certification Checklist	CMHC-Certification-Checklist.pdf	Yes	Yes	Fillable Fileable Signable
Other-Certification	Attachment 2 - RHCPP-Sample-Project-Coordinator-Certification.doc	Yes	Yes	Fillable Fileable Signable
Other-Vendor Certification	Attachment 3 - RHCPP-Sample-Vendor-Certification.doc	Yes	Yes	Fillable Fileable Signable
Other-Certification Checklist	Attachment 5 - RHC CMHC-Certification-Checklist.pdf	Yes	Yes	Fillable Fileable Signable
Other-Excel Template	Copy of Attachment 1 - Copy of Network Cost Worksheet Excel Template.xls	Yes	Yes	Fillable Fileable Signable
Other-Invoice Template	Copy of Attachment 4 - Copy of RHC Pilot Program_Invoice Template.xlsm	Yes	Yes	Fillable Fileable Signable
Other-Invoice Template	Copy of Attachment 6 - Copy of RHC Telecom Program_Invoice Template.xls	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,496

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	45,950	10,136	17,799	18,015
Annual IC Time Burden (Hours)	96,486	19,051	55,588	21,847
Annual IC Cost Burden (Dollars)	0	0	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.