Federal Government

OMB Control No. 3060-1271
Approved by OMB August, 2022

Estimated Time Per Response: 8hrs

CONNECTED CARE PILOT PROGRAM INSTRUCTIONS
Pilot projects participating in the Connected Care Pilot Program are required to submit the
following reports: an annual report after their first year of funding, an annual report after their
second year of funding, and a final report after their final year of funding that contains data for
the final year of funding, and summarizes final results. The first year for a particular Project
begins on the starting date for that Project.
Why the Federal Communications Commission Needs This Information:
The Federal Communications Commission (FCC) launched the Connected Care Pilot Program to
examine how the Universal Service Fund can help support the trend towards connected care
services, particularly for low-income Americans and veterans. The Pilot Program will provide
meaningful data that will help us better understand how Universal Service Funds can support
health care provider and patient use of connected care services. The data you provide will help
the FCC determine how it can support connected care services going forward. If your
organization does not collect the requested information, please select Did Not Track when
applicable. For questions that seek data from years prior to the start of the Pilot Program, please
provide any data that your organization has, even if that data is for less than a full year, or select
Did Not Track.
To minimize burdens on health care providers, the majority of questions are optional. If your
organization tracks information but you still decline to provide it, select Decline to Answer.
Report Submission:
Pilot projects must use the provided form to submit the required reports. The form may be
accessed through My Portal. The required reports can be submitted by any individual authorized
to submit the reports on behalf of a particular Pilot project. Failure to submit the required reports
may result in either the disqualification of the selected participant from the Pilot Program, loss or
reduction of support, or recovery of prior disbursements.
Reporting Deadlines:
The reports for the first and second year are due six months after the end of the first and second
year of the Project. The final report is due six months after the end date of the Project. The
project start date is the date that a Pilot project begins to receive supported services, and occurs
after the issuance of a Funding Commitment Letter by the Universal Service Administrator.
Questions About the Required Reports:
For questions concerning the completion or submission of the required reports please contact:
[email protected].
Definitions:
Broadband Internet Access Service: Mass market high speed Internet access service that is
always on and faster than traditional dial-up service. Broadband Internet access service can be

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offered through a variety of technologies, including digital subscriber line, cable modem, fiber,
wireless, satellite, and broadband over power line. The FCC did not adopt minimum service
standards for broadband Internet access service funded through the Pilot Program.
Connected Care: For purposes of the Pilot Program, “Connected Care” is defined as a “subset of
telehealth that uses broadband Internet access service-enabled technologies to deliver directly to
patients remote medical, diagnostic, and treatment-related services outside of traditional brick
and mortar medical facilities—specifically to patients at their mobile location or residence.”
This definition includes services such as remote patient monitoring and video visits, but does not
include audio-only (e.g., telephone) services.
Connected Care Pilot Program: The three-year, up to $100 Million Pilot Program established by
the FCC to examine how Universal Service Funds can support health care provider and patient
use of connected care services.
Federal Communications Commission (FCC or Commission): The federal agency responsible
for establishing, implementing and overseeing the Connected Care Pilot Program.
Low-Income Patient: For purposes of the Pilot Program, a patient is considered low-income if
(1) the patient is eligible for Medicaid or (2) the patient’s household income is at or below 135%
of the U.S. Department of Health and Human Services Federal Poverty Guidelines.
My Portal: My Portal is USAC’s online forms submission tool. My Portal is accessible from the
USAC website in the Rural Health Care section by following the links for “My Portal.”
Telehealth: For purposes of the Pilot Program, telehealth means the broad range of health carerelated applications that depend upon broadband connectivity, including telemedicine; exchange
of electronic health records; collection of data through Health Information Exchanges and other
entities; exchange of large image files (e.g., X-ray, MRIs, and CAT scans); and the use of realtime and delayed video conferencing for a wide range of telemedicine, consultation, training, and
other health care purposes. Where the term telehealth is used on the Pilot Program Reporting
template, the Commission is interested in information on telehealth services that are remote
clinical services.
Universal Service Administrative Company (USAC): The entity responsible for administering
the Connected Care Pilot Program, including processing Pilot Program forms.
Veteran Patient: For purposes of the Pilot Program, a patient is considered a veteran if the
patient qualifies for health care through the United States Department of Veterans Affairs (VA).
Sections:
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General Project Summary
Patient Population Questions
o 1.1a: Provide the estimated number of patients indicated on your original
application to participate in the Connected Care Pilot Program. Please use the
same figure reported on your original application.

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o 1.1b: If tracked, provide the number of unique patients served by the sites
participating in your Pilot project. Indicate total patients, number that are lowincome, number that are veterans, and the number that are both low-income and
veterans. The data provided in response to this question should include all unique
patients served by all sites participating in your Pilot project, regardless of
whether the patients are participating in your Pilot project. Each unique patient
should only be counted once. If you did not track a specific data point included
this question, please respond “did not track” in the provided field.
o 1.1c: If tracked, provide the number of unique patients that were eligible to
participate in the Connected Care Pilot project regardless of whether they actually
participated in it. Indicate total patients, number that are low-income, number
that are veterans, and the number that are both low-income and veterans. Each
unique patient should only be counted once. If you did not track a specific data
point included this question, please respond “did not track” in the provided field.
o 1.1d: Provide the number of unique patients that were included in your Connected
Care Pilot project and used connected care services during the current reporting
period. Patients that were included in the Pilot project but that did not use
connected care services should not be included. Indicate total patients, number
that are low-income, number that are veterans, and the number that are both lowincome and veterans. Each unique patient should only be counted once.
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Program Goals Questions
o 1.2a: Select Yes or No to indicate whether your organization is on track to meet
the objectives and goals that you set for your Pilot project.
o 1.2b: If the response to 1.2a is No, select the primary reason from the options:
Lack of provider participation; Lack of patient participation; Administrative
issues; Technical issues; Other.
o 1.2c: If the response to 1.2b is Other, provide an additional narrative explanation
in the provided field.
o 1.2d-g: Select the most appropriate response to each statement from the following
options: Strongly Disagree; Disagree; Somewhat disagree; Neither agree nor
disagree; Somewhat agree; Agree; Strongly Agree; No interference with meeting
objectives.

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Overall Satisfaction Questions
o 1.3a – 1.3d: Select the most appropriate response from the following options:
Extremely unsatisfied; Very unsatisfied; Unsatisfied; Not unsatisfied nor satisfied;
Satisfied; Very satisfied; Extremely satisfied.
o 1.3e: Select the most appropriate response from the following options: Extremely
unsatisfied; Very unsatisfied; Unsatisfied; Not unsatisfied nor satisfied; Satisfied;
Very satisfied; Extremely satisfied; Not applicable.

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o 1.3f: Select the most appropriate response from the following options: Extremely
unsatisfied; Very unsatisfied; Unsatisfied; Not unsatisfied nor satisfied; Satisfied;
Very satisfied; Extremely satisfied.
o 1.3g: Select the most appropriate response from the following options regarding
whether Pilot Program funding met your Pilot project’s needs: It covers 75-85%
of the amount needed; It covers 50-74.99% of the amount needed; It covers 2549.99% of the amount needed; It covers .01-24.99% of the amount needed. There
is no option indicating that the Pilot Program covers more than 85% of the
amount needed because the discount rate for the Pilot Program is 85%.
o 1.3h: (Optional) Provide any other feedback on the administration of the Pilot
Program in narrative in the field provided.
Provider Focused Questions
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Telehealth Appointment Questions
o 2.1a: Select Yes or No to indicate whether your organization received funding
from outside sources for telehealth aside from the Connected Care Pilot Program
in the 24 months preceding the end of the current reporting period. Funding aside
from the Connected Care Pilot Program could be funding from other government
sources (including other FCC programs), private grants, or private funding.
Telehealth funding includes devices and services outside the scope of the Pilot
Program that are related to the provision of Connected Care services.
o 2.1b: If you responded “Yes” to question 2.1a, please select all sources for
external funding for telehealth that you received in the 24 months preceding the
end of the current reporting period. Select all responses that apply: Other FCC
program(s); Other federal (non-FCC) program(s); Other state/local government
program(s); Private funding; Other, please specify. If you select “Other, please
specify” please provide a brief description of the funding source category in the
field provided next to the drop-down option.
o 2.1c: Indicate how funding from the Connected Care Pilot Program changed the
number of patients you served via connected care during the reporting period.
Select the most appropriate response from the following options: It decreased the
number of patients served; It did not affect the number of patients served; It
increased the number of patients served by less than 10%; It increased the number
of patients served by 10-20%; It increased the number of patients served by more
than 20%; Did not track.
o 2.1d: (Optional) Indicate how providing Connected Care Pilot Program services
changed the number of patients (including patients served under this program)
that providers were capable of seeing per day. Select the most appropriate
response from the following options: It did not affect the number of appointments
a provider could have per day; It decreased the number of appointments a
provider could have per day; It increased the number of appointments a provider

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could have per day by 1; It increased the number of appointments a provider
could have per day by 2; It increased the number of appointments a provider
could have per day by 3; It increased the number of appointments a provider
could have per day by more than 3; Did not Track; Project not focused on
appointments (Remote Patient Monitoring projects only) or Decline to answer.
o 2.1e: (Optional) Indicate how providing care via the Connected Care Pilot
Program changed the number of appointments a patient had on average during
this reporting period. Select the most appropriate response from the following
options: It decreased the average number of appointments; It did not affect the
average number of appointments; It increased the average number of
appointments per patient by less than 5%; It increased the average number of
appointments per patient by 5-10%; It increased the average number of
appointments per patient by 10-15%; It increased the average number of
appointments per patients more than 15%; Did not Track; Project not focused on
appointments (Remote Patient Monitoring projects only) or Decline to answer.
o 2.1f: (Optional) Indicate whether providing care via the Connected Care Pilot
Program services lead to providers seeing patients outside of standard hours of
operation: Select Yes, No, Not Applicable, or Decline to answer.
o 2.1g: (Optional) In the provided narrative box, identify the telehealth platforms or
services that your organization used to provide connected care services through
your Pilot project. For example, this could include the name of a service used for
providing video visits.
o 2.1h: (Optional) Provide any aggregated, anonymized metrics regarding the
number of patients provided with connected care service as a result of the Pilot
Program. Data can be uploaded as a pdf or in the native format (e.g., Excel
spreadsheet or Access database) in which it is held by your organization.
o 2.1i: (Optional) If tracked, provide information for two years prior to the start of
your Pilot project, one year prior to start of your Pilot project, and for the current
Reporting Period: Total number of unique patients in the Connected Care Pilot
Program (this field applies only to the current Reporting Period); Total number of
connected care appointments for patients in the Connected Care Pilot Program
(this field applies only to the current Reporting Period); Total number of patients
in Connected Care Pilot Program that use remote patient monitoring or
asynchronous connected care services as part of pilot project (this field applies
only to the current Reporting Period); Total number of unique patients served by
the participating hospital or health care provider; Total number of connected care
appointments across the entire patient population for sites participating in the
Pilot program; Total number of patients across entire patient population for
participating sites that uses remote patient monitoring or asynchronous connected
care services. If you did not track some of the specific data points requested in
these questions, please enter “did not track” in the provided field.
Patient Participation Questions

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o 2.2a: Select Yes or No to indicate whether your organization used Pilot Program
funding to obtain patient broadband Internet access service. In responding to this
question and questions 2.2b and 2.2c you should include Pilot-funded broadband
Internet access service provided directly to the individual patient, and Pilotfunded broadband Internet access service that the health care provider uses to
provide connected care services to the patient in the patient’s residence or other
location of the patient’s choosing that is not a health care provider site (e.g., your
staff meets with the patient in their home).
o 2.2b: If the answer to 2.2a is Yes, how many patients did the funded patient
Internet access service cover during the current reporting period. Provide a
number. If your answer to 2.2a is No, please enter “N/A” in the provided field.
o 2.2c: What percentage of patients receiving connected care services did so
through patient broadband Internet access service funded through the Connected
Care Pilot Program. Provide a percentage. If your answer to 2.2a is No, please
enter “N/A” in the field provided.
Provider Cost Questions
o 2.3a: Select Yes, No, I don’t know, or Decline to answer to indicate whether
providing connected care services through the Connected Care Pilot program led
to increased savings for the health care provider.
o 2.3b – 2.3d: If the response to 2.3a is Yes, please respond by selecting Yes, No, I
don’t know, or Decline to answer for each of the questions, and if tracked provide
any estimated savings in dollars for each question. If you did not track cost
savings in the specific listed areas, respond “did not track” in the provided fields.
Patient Outcome Questions
o 2.4a – 2.4h: (Optional) If tracked, for the year prior to the start of the Pilot
Program and the current reporting period provide information about patients who
later participated in the Pilot Program and total patient population for sites
participating in the Pilot Program requested in each question. The questions
address missed or cancelled appointments, emergency room visits, hospital
admissions, adherence to treatment plans, and length of hospital stays. If the
information is not tracked, enter “did not track” in the appropriate response box.
Specific Condition Outcome Questions
o 2.5a: The question addresses all medical conditions that are the focus of the Pilot
Program. Select the estimated percentage that corresponds to the health outcome
improvements observed as a result of using connected care services. If the
percentage of patients with improved health outcomes is not known, select
Unknown.
Additional Feedback
o 2.6a: Provide any relevant aggregated, anonymized metrics that are not captured
by the questions above for the reporting period concerning the number of patients
served through your Pilot project, health care provider cost savings, the impact of
funding patient broadband, patient outcomes, or specific health outcomes: (e.g.,

OMB Control No. 3060-1271
reductions in A1C levels for diabetic patients, reductions in blood pressure levels
for patients with high blood pressure). Data can be uploaded as a pdf or in the
native format (e.g., Excel spreadsheet or Access database) in which it is held by
your organization.
Patient Experience Questions
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Customer Satisfaction Questions
o 3.1a: Select the most appropriate response regarding how overall patient
satisfaction is tracked by your organization from the following options: Patient
survey; Complaints filed; Anecdotal evidence from providers; We do not track
this information; or Other, please specify. If you select “Other, please specify”
please provide a brief description in the provided field.
o 3.1b: Indicate your level of agreement with the following statement: Patients
generally report satisfaction with receiving treatment via the Connected Care Pilot
Program. Select the most appropriate response from the following options:
Strongly Disagree; Disagree; Somewhat disagree; Neither agree nor disagree;
Somewhat agree; Agree; Strongly Agree.
o 3.1c: If tracked, provide the percentage of Pilot patients that reported satisfaction
with receiving treatment by Connected Care during the reporting period. If you
did not track this information, please enter “did not track” in the provided field.
o 3.1d-3.1e: If tracked, provide, for the year prior to the start of the Pilot project and
the current reporting period, the average patient satisfaction in the Pilot Program
and across the entire patient population. Average patient satisfaction should be
determined by aggregating any tracked patient satisfaction data. Select the most
appropriate qualitative description from the following options: Extremely
unsatisfied; Very unsatisfied; Unsatisfied; Not unsatisfied nor satisfied; Satisfied;
Very satisfied; Extremely satisfied; Did not track.
Health Improvement Questions
o 3.2a: Select the most appropriate response from the following options: Patient
survey; Complaints filed; Anecdotal evidence from providers; We do not track
this information; Other, please specify. If you selected “Other,” please include a
description in the provided field.
o 3.2b: Provide the percentage of Pilot patients that reported an improvement in
health during the reporting period. Each unique patient (e.g., the same individual)
should only be counted once. Entering an approximate percentage is acceptable.
If you did not track this information, please respond “did not track” in the
provided field.
o 3.2c: Provide the percentage of Pilot patients that reported an improvement in
health in question 3.2b and attributed the improvement to receiving treatment via
connected care. Each unique patient (e.g., the same individual) should only be
counted once. Entering an approximate percentage is acceptable. If you did not
track this information, please respond “did not track” in the provided field.

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Cost Savings Questions
o 3.3a: If patient cost savings data were collected, provide a narrative explanation
about how those savings data were collected and tracked in the provided field.
o 3.3b: Select Yes or No to indicate whether any patients reported cost savings after
receiving treatment via connected care during the reporting period.
Time and Convenience Questions
o 3.4a: Select the most appropriate response regarding how your organization
collected and tracked time savings to patients using the following options: Patient
survey; Complaints filed; Anecdotal evidence from provider; We do not track this
information; Other, please specify. If you selected “Other,” please include a
description in the provided field.
o 3.4b – 3.4d: Select the most appropriate response from the following options to
indicate agreement with the statement in each question: Strongly Disagree;
Disagree; Somewhat disagree; Neither agree nor disagree; Somewhat agree;
Agree; Strongly Agree. If tracked, provide the estimated aggregate value of time
savings in hours across all patients for which you collected this data. If you did
not track the time savings, please enter “did not track” in the provided field.
Additional Feedback - Optional
o 3.5a: Provide any relevant anonymized, aggregated metrics on patient cost
savings or reductions in patient travel or time. Data can be uploaded as a pdf or in
the native format (e.g., Excel spreadsheet or Access database) in which it is held
by your organization.
o 3.5b: Provide any other feedback on the patient experience during the reporting
period. If you have feedback to share in this area, pleased provide a narrative
response in the provided field.

Connected Care Pilot Program Final Report
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Project Goals and Objectives Questions
o FR 1.1a: Select Yes or No to indicate for each option whether your project
advanced the FCC’s goals of the Pilot Program. The Pilot Program goals are:
Improving health outcomes through connected care; reducing health care costs for
patients, facilities, and health systems; and supporting the trend towards
connected care everywhere.
o FR 1.1b: Select all statements that are true for your project.
o FR 1.1c: Explain how your Pilot project met the FCC’s goals of the Pilot
Program. The Pilot Program goals are: Improving health outcomes through
connected care; reducing health care costs for patients, facilities, and health
systems; and supporting the trend towards connected care everywhere.
o FR 1.1d: If your project did not meet each of the Connected Care Pilot Program
goals, select the best options that explain why your Pilot project did not meet the
specific goals of the Pilot Program: Lack of patient participation, Lack of provider

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participation; Issues with distributing funding; Administrative issues; Other. If
you selected “Other” in response to this question, please provide a written
description of the “Other” issues in the provided field.
o FR 1.1e: Select Yes or No to indicate whether your project met the goals and
objectives that you set for it.
o FR 1.1f: If the response to FR 1.1e is Yes, explain in narrative form in the
provided field how your project met the goals and objectives that you set for it.
o FR 1.1g: If the response to FR 1.1e is No, explain in narrative form in the
provided field how your project did not meet the goals and objectives that you set
for it.
Lessons Learned Questions
o FR 1.2a: Select Yes or No to indicate whether as a result of your Pilot project, you
have any lessons learned to share.
o FR 1.2b: Select Yes or No to indicate whether you have lessons learned
concerning the goal of improving health outcomes through connected care. If the
response is Yes, please provide a written explanation in the provided field.
o FR 1.2c: Select Yes or No to indicate whether you have lessons learned
concerning the goal of reducing health care costs for patients, facilities, and health
care systems. If the response is Yes, please provide a written explanation in the
provided field.
o FR 1.2d: Select Yes or No to indicate whether you have lessons learned
concerning the goal of supporting the trend towards connected care everywhere. If
the response is Yes, please provide a written explanation in the provided field.
o FR 1.2e: Select Yes or No to indicate whether you have lessons learned
concerning the provision and use of connected care services, particularly for lowincome and veteran patients. If the response is Yes, please provide a written
explanation in the provided field.
o FR 1.2f: Select Yes or No to indicate whether you have lessons learned
concerning patient retention with respect to connected care services. If the
response is Yes, please provide a written explanation in the provided field.
o FR 1.2g: Select Yes or No to indicate whether you have lessons learned
concerning patient training and how best to address digital literacy challenges. If
the response is Yes, please provide a written explanation in the provided field.
o FR 1.2h: Select Yes or No to indicate whether you have other lessons learned that
are relevant to the FCC’s evaluation of the Pilot Program and its impact on
supporting connected care services. If the response is Yes, please provide a
written explanation in the provided field.

Certification
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Fill out each of the certification boxes and attest to the truthfulness of the information
you provide in the reporting form. The attestation can be completed by any individual
who is authorized to complete the report on behalf of the reporting organization(s) and is
able to attest to the truthfulness of the provided information.

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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 8 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-PPM, Paperwork Reduction Act Project (3060-1271), 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 3060-1271.
THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995,
P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.