NBAM Online Data Collection Form

OMB Control No. 0660-XXXX

Expiration Date: XX/XX/XXXX

NTIA Broadband Availability Data

Online Data Collection Form and Upload Tool

1. Overview

This document describes the online form and upload tool that NTIA will use to collect broadband availability data.

2. Online Form and Upload Tool

Question 1: Please submit the following general information about your organization. All fields are required.

Form Field	Field Type and Options
Organization Name	Text Field
Organization Type	Drop Down with the following options: Telecommunications Provider Electric Cooperative or Other Utility Not-for-Profit Higher Education or Academia Government - Federal Government - Local or Regional Government - State or Territory Government - Tribal Private Company Other
Organization Type - Other	Text Field; required if Organization Type = Other

Question 2: Please provide contact information for an individual that can answer questions about your organization’s response. All fields are required.

Form Field	Field Type and Options
First Name	Text Field
Last Name	Text Field
Title	Text Field
Phone Number	Text Field
Email Address	Text Field

Question 3: Please provide some general information about the broadband availability data you are submitting.

Form Field	Field Type and Options
Technology Type (check all that apply)	Wireline [Check Box] Wireless (Fixed) [Check Box] Wireless (Mobile) [Check Box] Wireless (Satellite) [Check Box]
Geospatial Type (check all that apply)	Coordinate (latitude/longitude) [Check Box] Address [Check Box] Address Range [Check Box] Road Segment [Check Box] Land Parcel [Check Box] Shapefile [Check Box] County [Check Box] Census Block [Check Box] Other (please specify via text field) [Check Box]
Geospatial Type - Other	Text Field; required if Geospatial Type = Other

Question 4: Please select the option that best aligns with the geographic scope of the data you are submitting.

Form Field	Field Type and Options
Geographic Scope	Drop Down with the following options: Local or Regional State Multi-state Nationwide Other
Geographic Scope - Other	Text Field; required if Geographic Scope = Other

Question 5: Please briefly summarize the data you are submitting.

Form Field	Field Type and Options
Data Summary	Text Area

Question 6: Please briefly describe the fields or metadata associated with the broadband availability data that your organization is submitting. If you prefer, this can be attached to your submission using the file upload tool.

Form Field	Field Type and Options
Data Dictionary or Schema	Text Area

Question 7: Please provide any additional feedback or comments that you will believe will help NTIA understand and process your organization’s submission.

Form Field	Field Type and Options
Additional Comments	Text Area

Question 8: Please upload the file(s) containing your data submission.

Form Field	Field Type and Options
Files	File Upload Dialog
Submit	Button