FCC Form 461 RHC, HFCP, Description of Request for Services (FY2020)

OMB 3060-0804

X/X/2020

Rural Health Care

Healthcare Connect Fund Program

Description of Request for Services (FCC Form 461)

Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see, the order in which they will see information, or the exact wording or directions used to collect the information. Where possible, information already provided by applicants from previous filing years or that was pre-filed in the system portal will be carried forward and auto-populated into the form.

This form is effective for funding year 2020.

Item #	Field Description	Purpose/Instructions
1	Applicant’s FCC Form Nickname	Optional. To create a unique identifier for this request, the user simply enters a nickname (e.g., 2016 Funding Year Homewood FCC Form 461).
2	Funding Year	This is the selection of the funding year the applicant is submitting the request for.
3	FCC Form 461 Application Number	Auto-generated by the system: This is a unique Universal Service Administrative Company (USAC)-assigned identifier for this request.
4	FCC Form 460 Number	Auto-generated by the system: Based on information for the previously submitted Description of Eligibility (FCC Form 460). This is a USAC-assigned unique identifier for this request.
5	FCC Form 461 Posting Start Date	Auto-generated by the system: This is a USAC-assigned date based on the date of submission of the request and review of the request.
6	FCC Form 461 Posting End Date	Auto-generated by the system: This is a USAC-assigned date based on no less than 28 days from the FCC Form 461 posting start date.
7	Allowable Contract Selection Date (ACSD)	Auto-generated by the system: This is a USAC-assigned date, plus any time added by the user, after which the applicant is able to enter into an agreement with a service provider. This date must be a date after the RFP and/or FCC Form 461 posting end date.
8	Site Name	Auto-populated by the system: This is the site name submitted on the FCC Form 460.
9	Site Number	Auto-populated by the system: This is the unique USAC-assigned identifier for this site listed in Site Name on the FCC Form 460.
10	Site Address	Auto-populated by the system: This is the site’s physical address, county, city, state, zip code, and geolocation submitted on the FCC Form 460. Geolocation only applies to a site that does not have a street address.
11	Consortium Name	Auto-populated by the system: This is the name the consortium submitted on the FCC Form 460.
12	Consortium Number	Auto-populated by the system: This is the unique USAC-assigned identifier for consortium listed in Site Name on the FCC Form 460.
13	Consortium Address	Auto-populated by the system: This is the consortium’s address, county, city, state, zip code and geolocation submitted on the FCC Form 460. Geolocation only applies to a consortium that does not have a street address.
14	FCC Registration Number	Auto-populated by the system: This is either the consortium or the site’s unique FCC registration number submitted via the FCC Form 460.
15	Indicate Whether a Separate Request for Proposals (RFP) will be Released for this Request	The user indicates whether they are issuing an RFP for the requested services. If an RFP is used, it must be attached to the FCC Form 461 so that it can be “released” with the posting of the FCC Form 461 and the RFP must be opened for at least 28 days after the posting of the FCC Form 461.
16	Letter of Agency (LOA)	For consortia only. The Consortium Leader is required to submit an LOA for each eligible health care provider participating in the consortium no later than when it submits its Request for Services (FCC Form 461).
17	Network Plan	For consortia only. If an applicant is a consortium, they must submit a narrative of its Network Plan with the FCC Form 461.
18	Services and/or Equipment Requested: Category	The user details which category(s) of services/activities it is requesting
19	Needs or Services Requested: Service/Activity Details	The user details any services/activities sought with the request.
20	Needs or Services and/or Equipment Requested: Applications & Usage	The user details the usage level and usage period for services/activities requested.
21	Services and/or Equipment Requested: Site(s) Listing	The user provides information on the sites/entities included in the request.
22	Services and/or Equipment Requested: Desired Contract Length	The user provides details on the length and type of contract requested.
23	Services and/or Equipment Requested: Bid Evaluation Period	Optional. The user can express how long after the end of the FCC Form 461 28-day posting period they will need to evaluate bids. The expected bid evaluation period is not part of the ACSD calculation.
24	Services and/or Equipment Requested: USAC Bid Posting Period	Optional. The user may add days to the posting period beyond the required minimum 28-day posting period. The system will only allow the applicant to enter a date that meets or exceeds the 28-day minimum requirement.
25	Bidding Evaluation	The user develops a weighted evaluation criteria (e.g., scoring matrix) that demonstrates how the applicant will choose the most ‘cost-effective' bid before submitting a request for services. Price must be a primary factor, but need not be the only primary factor. A non-price factor can receive an equal weight to price, but may not receive a greater weight than price.
26	Supporting Documentation	Optional. Users may also upload and submit any other supporting documents to support their request.
27	Contact Person Name	The user must provide the name of the person who should be contacted with questions about this request. This could be the Primary Contact, Additional Contact(s) or another person qualified to answer questions relating to the request.
28	Contact Person Employer	The user must provide the employer of the person who should be contacted with questions about this request.
29	Contact Person Title	The user must provide the title of the person who should be contacted with questions about this request.
30	Contact Person Mailing Address	The user must provide the mailing address of the person who should be contacted with questions about this request.
31	Contact Person Telephone Number	The user must provide the telephone number of the person who should be contacted with questions about this request.
32	Contact Person Email Address	The user must provide the email address of the person who should be contacted with questions about this request.
33	Contact Person Fax Number	The user must provide the fax number of the person who should be contacted with questions about this request.
34	Declaration of Assistance/Consultant or Outside Expert Information	If applicable. If the user uses a consultant, service provider, or any other outside expert, whether paid or unpaid, who aided in the preparation of its request and/or RFP, the user must provide the name of the company, name of the person representing the applicant, title of the person representing the applicant, telephone number, email address, and physical address.
35	I certify under penalty of perjury that I am authorized to submit this request on behalf of the health care provider or consortium.	The Authorized Person is required to provide all certifications and signatures. For individual applicants, certifications must be signed by an officer or director of the applicant. For consortium applicants, an officer, director, or other authorized employee of the Consortium Leader must sign the required certification. The applicant is required to provide this certification in order to receive universal service support.
36	I certify under penalty of perjury that I have examined this request and all attachments, and to the best of my knowledge, information, and belief, all statements contained herein and in any attachments are true.	See Item #35 Purpose/Instructions above.
37	I certify under penalty of perjury that the applicant seeking supported services is a nonprofit or public entity that falls within one of the seven categories set forth in the definition of health care provider listed in 47 CFR §54.600 of the Commission’s rules.	See Item #35 Purpose/Instructions above.
38	I certify under penalty of perjury that the applicant seeking supported services is physically located in a rural area as defined in section 47 CFR § 54.600 of the Commission’s rules, or is a member of a consortium which satisfies the majority-rural composition requirements set forth in 47 CFR § 54.607 of the Commission’s rules.	See Item #35 Purpose/Instructions above.
39	I certify under penalty of perjury that the applicant seeking supported services has complied with any applicable state, Tribal, or local procurement rules.	See Item #35 Purpose/Instructions above.
40	I certify under penalty of perjury that all requested RHC Program support will be used solely for purposes reasonably related to the provision of health care service or instruction that the health care provider is legally authorized to provide under the law of the state in which the services are provided.	See Item #35 Purpose/Instructions above.
41	I certify under penalty of perjury that the services will not be sold, resold, or transferred in consideration for money or any other thing of value.	See Item #35 Purpose/Instructions above.
42	I certify under penalty of perjury that the applicant seeking supported services satisfies all of the requirements under section 254 of the Communications Act, 47 U.S.C. § 254, and applicable Commission rules.	See Item #35 Purpose/Instructions above.
43	I certify under penalty of perjury that the applicant seeking support has reviewed and is compliant with all applicable RHC Program requirements.	See Item #35 Purpose/Instructions above.
44	I understand that all documentation associated with this request, including a copy of the signed Request for Services (FCC Form 461), any bids/contracts resulting from the FCC Form 461 posting, scoring sheet, and other information that was used in the decision making process, must be retained for a period of at least five years pursuant to 47 CFR § 54.631, or as otherwise prescribed by the Commission’s rules.	See Item #35 Purpose/Instructions above.
45	Signature	The FCC Form 461 must be signed electronically.
46	Date Submitted	Auto generated by system.
47	Date Signed	Auto generated by system.
48	Authorized Person Name	The Authorized Person is required to provide all required certifications and signatures. This is the name of the Authorized Person certifying the FCC Form 461. This field will be auto-populated if the name of the Authorized Person is already within the system.
49	Authorized Person’s Employer	This is the name of the employer of the Authorized Person certifying the FCC Form 461. This field will be auto-populated if already within the system.
50	Authorized Person’s Employer FCC Registration Number	This is the FCC registration number of the Authorized Person certifying the FCC Form 461. This field will be auto-populated if already within the system.
51	Authorized Person’s Title/Position	This is the title of the Authorized Person certifying the FCC Form 461. This field will be auto-populated if already within the system.
52	Authorized Person’s Mailing Address	This is the address (can be physical address or mailing address) of the Authorized Person certifying the FCC Form 461. This field will be auto-populated if already within the system.
53	Authorized Person Telephone Number	This is the telephone number of the Authorized Person certifying the FCC Form 461. This field will be auto-populated if already within the system.
54	Authorized Person Email Address	This is the email address of the Authorized Person certifying the FCC Form 461. This field will be auto-populated if already within the system.

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 54 of the Federal Communications Commission’s (FCC) rules authorize the FCC to collect the information in this form. Responses to the questions herein are required to obtain the benefits sought by this form. Failure to provide all requested information will delay the processing of the form or result in the form being returned without action. Information requested by this form will be available for public inspection. The information provided will be used to determine whether approving the request is in the public interest.

We have estimated that your response to this collection of information will take 2 hours.  Our estimate includes the time to read the instructions, look through existing records, gather and maintain the 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, Paperwork Reduction Act Project (3060‑0804), Washington, DC 20554.  We will also accept your comments via the Internet if you send them to [email protected].  Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.  

Remember – 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 or we fail to provide you with this notice.  This collection has been assigned an OMB control number of 3060‑0804.

THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

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