Federal Government

OMB Control No. 3060-1271

Estimated Time Per Response: 8 hours

Approved by OMB August, 2022

Connected Care Pilot Program Questionnaire
General Project Summary
Applicant Name:
Project Coordinator Name:
Reporting period: Drop-down menu:
Year 1
Year 2
Year 3
Patient Population Questions

1.1a

Answers:

What is the estimated number of patients indicated on your original application to
participate in the Connected Care Pilot Program?
In Total

1.1b
1.1c
1.1d

1.2a

That are Low Income,
if tracked

How many unique patients do you serve (if you track this):
How many unique patients were eligible for your Connected Care Pilot project (if
you track this):
How many patients were included in your Connected Care Pilot project AND used
connected services during this reporting period:
Program Goals Questions:
Are you on track to meet the objectives and goals of your Connected Care Pilot project?

1.2b If you responded no to 1.2a, please choose the primary reason you are not on track to meet the
objectives of your Connected Care Pilot project.

1.2c Please explain further if you chose "other" in 1.2b:
1.2d Please state your response to the following statement: Lack of health care provider participation
interfered with meeting the objectives of your Connected Care Pilot project.

Answers:
Drop-down menu options:
Yes
No
Drop-down menu options:
Lack of provider participation
Lack of patient participation
Administrative Issues
Technical issues
Other
Drop-down menu options:
Strongly Disagree
Disagree

That are a Veteran, if
tracked

That are Both Low
Income & Veteran, if
tracked

OMB Control No. 3060-1271

1.2e

Please state your response to the following statement: Lack of patient participation interfered with
meeting the objectives of your Connected Care Pilot project.

1.2f

Please state your response to the following statement: Administrative issues interfered with meeting
the objectives of your Connected Care Pilot project.

1.2g

Please state your response to the following statement: Technical issues interfered with meeting the
objectives of your Connected Care Pilot project.

1.3a

Overall Satisfaction Questions:
How satisfied were you with how your Connected Care Pilot project has been implemented
internally?

Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Agree
Strongly Agree
No interference with meeting
objectives
Drop-down menu options:
Strongly Disagree
Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Agree
Strongly Agree
No interference with meeting
objectives
Drop-down menu options:
Strongly Disagree
Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Agree
Strongly Agree
No interference with meeting
objectives
Drop-down menu options:
Strongly Disagree
Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Agree
Strongly Agree
No interference with meeting
objectives
Answers:
Drop-down menu
options:
Extremely unsatisfied
Very unsatisfied
Unsatisfied
Not unsatisfied nor
satisfied
Satisfied
Very satisfied
Extremely satisfied

OMB Control No. 3060-1271
1.3b

How satisfied were you with the FCC's administration of the Connected Care Pilot Program?

1.3c

How satisfied were you with your experience navigating the Program websites and My Portal?

1.3d

How satisfied were you with the ease and clarity of filing required FCC forms?

1.3e

How satisfied were you with USAC's ability to help with questions in a timely manner?

1.3f

How satisfied were you with the timeframe in which you received a funding commitment?

Extremely unsatisfied
Very unsatisfied
Unsatisfied
Not unsatisfied nor
satisfied
Satisfied
Very satisfied
Extremely satisfied

1.3g

How much does the Program funding meet your Connected Care Pilot project’s needs?

Drop-down menu
options:
It covers 75-85% of the
amount needed
It covers 50-74.99% of
the amount needed

Extremely unsatisfied
Very unsatisfied
Unsatisfied
Not unsatisfied nor
satisfied
Satisfied
Very satisfied
Extremely satisfied
Extremely unsatisfied
Very unsatisfied
Unsatisfied
Not unsatisfied nor
satisfied
Satisfied
Very satisfied
Extremely satisfied
Extremely unsatisfied
Very unsatisfied
Unsatisfied
Not unsatisfied nor
satisfied
Satisfied
Very satisfied
Extremely satisfied
Extremely unsatisfied
Very unsatisfied
Unsatisfied
Not unsatisfied nor
satisfied
Satisfied
Very satisfied
Extremely satisfied
Not applicable

OMB Control No. 3060-1271

1.3h

(Optional) If you would like to share any other thoughts or feedback on the administration of the
Connected Care Pilot Program for this reporting period please do so here:

It covers 25-49.99% of
the amount needed
It covers 0.01-24.99% of
the amount needed
[Narrative response]

Provider Focused Questions
Telehealth Appointment Questions
2.1a Did you receive external funding for telehealth services outside
of the Connected Care Pilot Program in the last 24 months
preceding the end of the current reporting period?
2.1b If you answered Yes to 2.1a, what was (were) the other source(s)
of the external funding? (Please select all that applied.)

Answers:

Drop-down menu options:
Yes
No
Select all that applied:
Other FCC program(s)
Other federal (non-FCC) program(s)
Other state/local government program(s)
Private funding
Other, please specify
2.1c How did funding from the Connected Care Pilot Program change Drop-down menu options:
the number of patients you served via connected care during the It decreased the number of patients served.
reporting period?
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.
2.1d (Optional) How did providing Connected Care Pilot Program
Drop-down menu options:
services change the number of patients (including patients served It did not affect the number of appointments a provider could have per day.
under this program) doctors were capable of seeing see per day? It decreased the number of appointments a provider could have per day.
It increased the number of appointments a provider 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 or Project not focused on appointments.
Decline to answer.
2.1e (Optional) How did providing care via Connected Care Pilot
Drop-down menu options:
Program services change the number of appointments a patient
It decreased the average number of appointments.
had on average during this reporting period?
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 patient more than 15%.
Did not track or Project not focused on appointments.
Decline to answer.

OMB Control No. 3060-1271
2.1f

(Optional) Did providing care via Connected Care Pilot Program
services lead to providers seeing patients outside of standard
hours of operation?

2.1g

(Optional) Please identify the telehealth platforms/services that
you used to provide connected care services through your
Connected Care Pilot project.
2.1h (Optional) Please provide an anonymized aggregated number of
patients that you were able to provide connected care services to
through your Pilot project.

Drop-down menu options:
Yes
No
Not Applicable
Decline to Answer
[Narrative response]
[PDF or native format upload]

Two Years Prior, If Tracked
(two years prior to the pilot starting)

2.1i

Total number of unique patients in the Connected Care Pilot
Program.
(Optional) Total number of connected care appointments for
patients included in the Connected Care Pilot Program.
(Optional) Total number of Pilot project patients using remote
patient monitoring or asynchronous connected care services as
part of your Pilot project.
Total number of unique patients served by the
hospital/organization.
(Optional) Total number of connected care appointments across
entire patient population.
(Optional) Total number of patients using remote patient
monitoring or asynchronous connected care services across
entire patient population.

2.2a

Patient Participation Questions
Did you use the Connected Care Pilot Program funding to obtain patient broadband
Internet access service?

2.2b

If you answered yes to 2.2a, how many patients did the funded patient Internet access
service cover during this reporting period?

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?

2.3a

Provider Cost Questions
Did providing connected care services through the Connected Care Pilot
Program lead to increased savings for the health care provider?

Answers:
Drop-down menu options:
Yes
No

Answers:
Drop-down menu options:
Yes
No

Prior Year, If
Tracked
(in the year
prior to
the pilot
starting)

Reporting Year, If Tracked
(in the reporting year since the pilot began)

OMB Control No. 3060-1271
I don’t know
Decline to answer

If you answered "yes" to question 2.3a, please answer the following:

Estimated Value, if tracked

2.3b

Did providing Connected Care services reduce health practitioner's time
per appointment?

Drop-down menu options:
Yes
No
I don’t know
Decline to answer

2.3c

Did providing Connected Care services reduce equipment purchases or
use costs?

2.3d

Did providing Connected Care services reduce use of higher level care
settings (e.g., ER)?

Drop-down menu options:
Yes
No
I don’t know
Decline to answer
Drop-down menu options:
Yes
No
I don’t know
Decline to answer

Patient Outcome Questions

2.4a
2.4b
2.4c
2.4d
2.4e
2.4f
2.4g
2.4h

Answers:
Prior Year, if Tracked
(in the year prior to the pilot starting)

(Optional) Total Missed or Cancelled Appointments (All Patients)
(Optional) Total Missed or Cancelled Appointments (Connected Care Pilot
Patients)
(Optional) Total Emergency Room Visits (All Patients)
(Optional) Total Emergency Room Visits (Connected Care Pilot Patients)
(Optional) Total Hospital Admissions (All Patients)
(Optional) Total Hospital Admissions (Connected Care Pilot Patients)
(Optional) Average Length (in Days) of Hospital Stays (All Patients)
(Optional) Average Length (in Days) of Hospital Stays (Connected Care Pilot
Patients)

Specific Condition Outcome Questions

Answers:

Reporting year , if Tracked
(in the reporting year since the pilot began)

OMB Control No. 3060-1271
2.5a

2.6a

As a result of the connected care services provided through your Connected Care Pilot
project, what percentage of patients do you estimate had improved health outcomes during
the reporting period?

Drop-down menu options:

Additional Feedback
Please provide any relevant aggregated, anonymized metrics not already captured above
concerning the number of patients served through your Connected Care Pilot project,
health care provider cost savings, the impact of funding patient broadband, patient
outcomes, or specific health outcomes for the reporting period.:

Answers:
[PDF or native format upload.]

Patient Experience Questions
3.1a

3.1b

Customer Satisfaction Questions:
How do you track overall patient satisfaction?

Please indicate your level of agreement with the
following statement: Patients generally report
satisfaction with receiving treatment via the
Connected Care Pilot program.

Answers:
Please select from the
following:
Patient survey
Complaints filed
Anecdotal evidence
from providers
We do not track this
information
Other, please specify
Drop-down menu
options:
Strongly Disagree
Disagree
Somewhat Disagree
Neither Agree nor
Disagree Somewhat
Agree
Somewhat Agree
Agree
Strongly Agree

0%
Less than 10%
10-20%
20-30%
30-40%
40-50%
50-60%
60-70%
70-80%
80-90%
90-100%
Unknown

OMB Control No. 3060-1271
3.1c

If tracked, what percentage of patients report
satisfaction with receiving treatment via the
Connected Care Pilot program?

3.1d

Aggregate patient satisfaction for patients in the
Connected Care Pilot program

3.1e

Aggregate patient satisfaction across the entire
patient population

3.2a

3.2b

Health
Improvement
Questions:
How did you track
patient health
satisfaction for
your Connected
Care Pilot project
and if so?

What approximate
percentage of
patients
participating in
your Connected

Answers:
Please select from the
following:
Patient surveys
Complaints filed
Anecdotal evidence
from providers
We do not track this
information
Other, please
specify_____

Prior Year, if Tracked
(in the year prior to
the pilot starting)
Drop-down menu
options:
Extremely unsatisfied
Very unsatisfied
Unsatisfied
Not unsatisfied nor
satisfied
Satisfied
Very satisfied
Extremely satisfied
Did not track
Drop-down menu
options:
Extremely unsatisfied
Very unsatisfied
Unsatisfied
Not unsatisfied nor
satisfied
Satisfied
Very satisfied
Extremely satisfied
Did not track

Reporting Year, if Tracked
(in the reporting year since
the pilot began)
Drop-down menu options:
Extremely unsatisfied
Very unsatisfied
Unsatisfied
Not unsatisfied nor satisfied
Satisfied
Very satisfied
Extremely satisfied
Did not track
Drop-down menu options:
Extremely unsatisfied
Very unsatisfied
Unsatisfied
Not unsatisfied nor satisfied
Satisfied
Very satisfied
Extremely satisfied
Did not track

OMB Control No. 3060-1271

3.2c

Care Pilot project
reported an
improvement in
their health (e.g.,
reduction in acute
incidents) during
the reporting
period?
Of the patients that
reported an
improvement in
their health, what
approximate
percentage attribute
that improvement
to receiving
treatment via the
Connected Care
Pilot program?
Cost Savings Questions:

3.3a

If you collected data on cost savings for patients as a result of the Connected
Care Pilot program, how did you collect and track these savings?

3.3b

Have any patients reported any cost savings by receiving treatment via the
Connected Care Pilot program during the reporting period?

Time & Convenience Questions:
3.4a

If you collected data on cost savings to patients' time as a result of the
Connected Care Pilot program, how did you collect and track these savings?

Answers:
Drop-down menu
options:
Patient survey
Complaints filed
Anecdotal evidence
from providers
We do not track this
information
Other, please
specify _____
Drop down menu
options:
Yes
No
Answers:

Answers:
Drop-down menu
options:
Patient survey

Aggregated Estimated
Value, if tracked

OMB Control No. 3060-1271
Complaints filed
Anecdotal evidence
from providers
We do not track this
information
Other, please
specify _____
Answers:
3.4b

Receiving treatment via the Connected Care Pilot program enabled your
patients to experience a reduction in travel time.

3.4c

Receiving treatment via the Connected Care Pilot program enabled your
patients to experience a reduction in time taken off work or time away from
school/classes

3.4d

Receiving treatment via the Connected Care Pilot program enabled your
patients to experience shorter waiting time.

3.5a

Additional Feedback - Optional
Please provide any relevant anonymized, aggregated metrics on patient cost
savings, reductions in patient travel or time.

Drop-down menu
options:
Strongly Disagree
Disagree
Somewhat Disagree
Neither Agree nor
Disagree
Somewhat Agree
Agree
Strongly Agree
Did Not Track
Drop-down menu
options:
Strongly Disagree
Disagree
Somewhat Disagree
Neither Agree nor
Disagree
Somewhat Agree
Agree
Strongly Agree
Did Not Track
Drop-down menu
options:
Strongly Disagree
Disagree
Somewhat Disagree
Neither Agree nor
Disagree
Somewhat Agree
Agree
Strongly Agree
Did Not Track

Answers:
[PDF or native format
upload]

Aggregated Estimate of
Time Savings in Hours,
If Tracked

OMB Control No. 3060-1271
3.5b

If you would like to share any other thoughts or feedback on the patient
experience for this reporting period please do so here:

[Narrative response]

Final Report
Project Goals and Objectives Questions
Did your project advance the goals of the Connected Care Pilot Program? (i.e.,
Improving health outcomes through connected care; reducing health care costs for
patients, facilities, and health systems; and supporting the trend towards connected care
everywhere)

Answers
Drop-down options:
Yes
No

FR 1.1b

Select the following statements that were true for your project.

FR1.1c
FR 1.1d

Please explain how your project met each of the Connected Care Pilot Program goals.
If your project did not meet each of the Connected Care Pilot Program goals, choose
the primary reason why not.

Select all that apply:
My Connected Care Pilot project
reduced healthcare costs.
My Connected Care Pilot project
improved health outcomes.
My Connected Care Pilot project
supported connected care
everywhere.

FR. 1.1e

Did your project meet the goals and objectives that you set for it?

FR 1.1f

If yes, please provide a brief explanation of the goals and objectives that your
Connected Care Pilot project met.

FR. 1.1g

If your Connected Care Pilot project did not meet the goals and objectives you set for
it, please explain why not.

FR 1.1a

Select all that apply:
Lack of provider participation
Lack of patient participation
Administrative issues
Technical issues
Other, please specify_________
Drop-down options:
Yes
No
[Narrative response]

FR 1.2a

Lessons Learned
As a result of your Connected Care Pilot project, do you have any lessons learned to
share in the following areas that would be relevant to the FCC's evaluation of the Pilot
Program and its impact on supporting connected care services?

Answers:
Drop-down options:
Yes
No

FR
1.2b

Lessons learned concerning the goal of improving health outcomes through connected
care.

Drop-down options:
Yes
No
Narrative Response

If the answer to FR 1.2b is Yes, please explain.

OMB Control No. 3060-1271
FR 1.2c

Lessons learned concerning the goal of reducing health care costs for patients,
facilities, and health care systems.
If the answer to FR 1.2c is Yes, please explain.

FR
1.2d

Lessons learned concerning the goal of supporting the trend towards connected care
everywhere.
If the answer to FR 1.2d is Yes, please explain.

FR 1.2e

Lessons learned concerning the provision and use of connected care services,
particularly for low-income and veteran patients.
If the answer to FR 1.2e is Yes, please explain.

FR 1.2f

Lessons learned concerning patient retention with respect to connected care services.
If the answer to FR 1.2f is Yes, please explain.

FR
1.2g

Lessons learned concerning patient training and how best to address digital literacy
challenges.
If the answer to FR 1.2g is Yes, please explain.

FR
1.2h

Drop-down options:
Yes
No
Narrative Response
Drop-down options:
Yes
No
Narrative Response
Drop-down options:
Yes
No
Narrative Response
Drop-down options:
Yes
No
Narrative Response
Drop-down options:
Yes
No
Narrative Response

Do you have any other lessons learned relevant to the FCC's evaluation of the
Connected Care Pilot Program and its impact on supporting connected care services?

Drop-down options:
Yes
No

If the answer to FR 1.2h is Yes, please explain.

Narrative Response

Certification
Certification
I certify that I am [Enter Job Title]
[Enter Exact Legal Name of Respondent]

of

and that I have examined the responses to the Connected Care Pilot Program Yearly Data Report, and that to the best of
my knowledge and belief, all responses are true, correct, and complete.

OMB Control No. 3060-1271
Signature: [Enter Digital Signature]
Full Name: [Enter Full Name]
Date: [Enter Date in MM/DD/YY Format]
Telephone Number: [Enter Telephone Number]
E-mail Address: [Enter E-mail Address]
Please list the names of all the legal entities, U.S. subsidiaries, or affiliations that are included in the data entered
on this form: [Enter list separated by semicolons]
Willful false statements in responses to this information collection are punishable by fine and/or imprisonment
(U.S. Code, Title 18, Section 1001).
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