Information Collection

Universal Service - Rural Health Care Program

IC 199666 under ICR 202102-3060-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 1 - (11.8.19) Post-Commitment Request Form - Effective FY 2021 (4.7.20).docx	Other-Post Commitment Form (FY2021)
Attachment 1 - (11.8.19) Post-Commitment Request Form - Effective FY 2021 (4.7.20).docx	Other-Post Commitment Form (FY2021)
Attachment 1 - (11.8.19) Post-Commitment Request Form - Effective upon OMB approval (4.7.20).docx	Other-Post Commitment Form
Attachment 1 - (11.8.19) Post-Commitment Request Form - Effective upon OMB approval (4.7.20).docx	Other-Post Commitment Form
Attachment 3 - RHC CMHC-Certification-Checklist (4.3.20).docx	Other-CMHC - Certification Checklist
Attachment 3 - RHC CMHC-Certification-Checklist (4.3.20).docx	Other-CMHC - 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 - 54.633

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Post Commitment Form (FY2021)	Attachment 1 - (11.8.19) Post-Commitment Request Form - Effective FY 2021 (4.7.20).docx	Yes	Yes	Fillable Fileable Signable
Other-Post Commitment Form	Attachment 1 - (11.8.19) Post-Commitment Request Form - Effective upon OMB approval (4.7.20).docx	Yes	Yes	Fillable Fileable Signable
Other-CMHC - Certification Checklist	Attachment 3 - RHC CMHC-Certification-Checklist (4.3.20).docx	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,498

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: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	31,229	31,229
Annual IC Time Burden (Hours)	127,580	127,580
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.