Universal Service - Health Care Providers Universal Service Program

Universal Service - Rural Health Care Program/Rural Health Care Pilot Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-0804 can be found here:

Documents and Forms

Document Name Document Type
Form FCC Form 465 Universal Service - Health Care Providers Universal Service Program Form and Instruction
FCC Form 465 Health Care Providers Universal Service, Description of 0804_Form 465.xls www.usac.org/rhc/tools/required-forms.aspx Form and Instruction
FCC Form 466 Health Care Providers Universal Service, Funding Request 0804_Form 466.xls www.usac.org/rhc/tools/required-forms.aspx Form and Instruction
FCC Form 466-A Health Care Providers Universal Service, Internet Servic 0804_Form 466-A.xls www.usac.org/rhc/tools/required-forms.aspx Form and Instruction
FCC Form 467 Health Care Providers Universal Service, Connection Cert 0804_FORM 467.xls www.usac.org/rhc/tools/required-forms.aspx Form and Instruction

Information Collection (IC) Details

IC Title:	Universal Service - Health Care Providers Universal Service Program	Agency IC Tracking Number:	WCB

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 47 CFR 54.601-54.625

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FCC Form 465	Health Care Providers Universal Service, Description of Services Requested & Certification Form	0804_Form 465.xls	http://www.usac.org/rhc/tools/required-forms.aspx	Yes	Yes	Fillable Printable
Form and Instruction	FCC Form 466	Health Care Providers Universal Service, Funding Request and Certification Form	0804_Form 466.xls	http://www.usac.org/rhc/tools/required-forms.aspx	Yes	Yes	Fillable Printable
Form and Instruction	FCC Form 466-A	Health Care Providers Universal Service, Internet Service Funding Request and Certification Form	0804_Form 466-A.xls	http://www.usac.org/rhc/tools/required-forms.aspx	Yes	Yes	Fillable Printable
Form and Instruction	FCC Form 467	Health Care Providers Universal Service, Connection Certification	0804_FORM 467.xls	http://www.usac.org/rhc/tools/required-forms.aspx	Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,494	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Previously Approved
Annual Number of Responses for this IC	59,464	59,464
Annual IC Time Burden (Hours)	68,420	68,420
Annual IC Cost Burden (Dollars)	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.