Federal Government

Universal Service - Rural Health Care Program

Documents and Forms

Document Name Document Type
Post-Commitment Request Form (v.3 2.18.24) CLEAN.pdf Other-Post Commitment Form
Post-Commitment Request Form (v.3 2.18.24) CLEAN.pdf Other-Post Commitment Form
CMHC-Certification-Checklist (Nov 2023).pdf Other-CMHC Certification Checklist
CMHC-Certification-Checklist (Nov 2023).pdf Other-CMHC Certification Checklist
Telecommunications Program Invoice Form (Nov 2023).pdf Other-RHC, Telecom Program, Invoice
Telecommunications Program Invoice Form (Nov 2023).pdf Other-RHC, Telecom Program, Invoice

Information Collection (IC) Details

IC Title:	Federal Government	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 54.601(b) 47 CFR 54.601(c)

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Post Commitment Form	Post-Commitment Request Form (v.3 2.18.24) CLEAN.pdf	Yes	Yes	Fillable Fileable Signable
Other-CMHC Certification Checklist	CMHC-Certification-Checklist (Nov 2023).pdf	Yes	Yes	Fillable Fileable Signable
Other-RHC, Telecom Program, Invoice Form	Telecommunications Program Invoice Form (Nov 2023).pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,284	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	39,024	222	38,802
Annual IC Time Burden (Hours)	147,463	91	147,372
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.