Federal Government

OMB Control No. 3060-1271

Approved by OMB [Month] 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	Answers:
1.1a	What is the estimated number of patients indicated on your original application to participate in the Connected Care Pilot Program?
		In Total	That are Low Income, if tracked	That are a Veteran, if tracked	That are Both Low Income & Veteran, if tracked
1.1b	How many unique patients do you serve (if you track this):
1.1c	How many unique patients were eligible for your Connected Care Pilot project (if you track this):
1.1d	How many patients were included in your Connected Care Pilot project AND used connected services during this reporting period:

	Program Goals Questions:	Answers:
1.2a	Are you on track to meet the objectives and goals of your Connected Care Pilot project?	Drop-down menu options:  Yes No
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.	Drop-down menu options:  Lack of provider participation Lack of patient participation Administrative Issues Technical issues Other
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.	Drop-down menu options:  Strongly Disagree Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Agree Strongly Agree  No interference with meeting objectives
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.	Drop-down menu options:  Strongly Disagree Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Agree Strongly Agree  No interference with meeting objectives
1.2f	Please state your response to the following statement: Administrative issues interfered with meeting the objectives of your Connected Care Pilot project.	Drop-down menu options:  Strongly Disagree Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Agree Strongly Agree  No interference with meeting objectives
1.2g	Please state your response to the following statement: Technical issues interfered with meeting the objectives of your Connected Care Pilot project.	Drop-down menu options:  Strongly Disagree Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Agree Strongly Agree  No interference with meeting objectives

	Overall Satisfaction Questions:	Answers:
1.3a	How satisfied were you with how your Connected Care Pilot project has been implemented internally?	Drop-down menu options:  Extremely unsatisfied Very unsatisfied Unsatisfied Not unsatisfied nor satisfied Satisfied Very satisfied Extremely satisfied
1.3b	How satisfied were you with the FCC's administration of the Connected Care Pilot Program?	Extremely unsatisfied Very unsatisfied Unsatisfied Not unsatisfied nor satisfied Satisfied Very satisfied Extremely satisfied
1.3c	How satisfied were you with your experience navigating the Program websites and My Portal?	Extremely unsatisfied Very unsatisfied Unsatisfied Not unsatisfied nor satisfied Satisfied Very satisfied Extremely satisfied
1.3d	How satisfied were you with the ease and clarity of filing required FCC forms?	Extremely unsatisfied Very unsatisfied Unsatisfied Not unsatisfied nor satisfied Satisfied Very satisfied Extremely satisfied
1.3e	How satisfied were you with USAC's ability to help with questions in a timely manner?	Extremely unsatisfied Very unsatisfied Unsatisfied Not unsatisfied nor satisfied Satisfied Very satisfied Extremely satisfied Not applicable
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 It covers 25-49.99% of the amount needed It covers 0.01-24.99% of the amount needed
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:	[Narrative response]

Provider Focused Questions

	Telehealth Appointment Questions	Answers:
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?	Drop-down menu options: Yes No
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.)	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 the number of patients you served via connected care during the reporting period?	Drop-down menu 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.
2.1d	(Optional) How did providing Connected Care Pilot Program services change the number of patients (including patients served under this program) doctors were capable of seeing see per day?	Drop-down menu 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 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 Program services change the number of appointments a patient had on average during this reporting period?	Drop-down menu 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 patient more than 15%.   Did not track or Project not focused on appointments. Decline to answer.
2.1f	(Optional) Did providing care via Connected Care Pilot Program services lead to providers seeing patients outside of standard hours of operation?	Drop-down menu options: Yes No Not Applicable  Decline to Answer
2.1g	(Optional) Please identify the telehealth platforms/services that you used to provide connected care services through your Connected Care Pilot project.	[Narrative response]
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.	[PDF or native format upload]
		Two Years Prior, If Tracked (two years prior to the pilot starting)	Prior Year, If Tracked (in the year prior to the pilot starting)	Reporting Year, If Tracked (in the reporting year since the pilot began)
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.

	Patient Participation Questions	Answers:
2.2a	Did you use the Connected Care Pilot Program funding to obtain patient broadband Internet access service?	Drop-down menu options: Yes No
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?

	Provider Cost Questions	Answers:
2.3a	Did providing connected care services through the Connected Care Pilot Program lead to increased savings for the health care provider?	Drop-down menu options: Yes No   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?	Drop-down menu options: Yes No   I don’t know Decline to answer
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

	Patient Outcome Questions	Answers:
		Prior Year, if Tracked (in the year prior to the pilot starting)	Reporting year , if Tracked (in the reporting year since the pilot began)
2.4a	(Optional) Total Missed or Cancelled Appointments (All Patients)
2.4b	(Optional) Total Missed or Cancelled Appointments (Connected Care Pilot Patients)
2.4c	(Optional) Total Emergency Room Visits (All Patients)
2.4d	(Optional) Total Emergency Room Visits (Connected Care Pilot Patients)
2.4e	(Optional) Total Hospital Admissions (All Patients)
2.4f	(Optional) Total Hospital Admissions (Connected Care Pilot Patients)
2.4g	(Optional) Average Length (in Days) of Hospital Stays (All Patients)
2.4h	(Optional) Average Length (in Days) of Hospital Stays (Connected Care Pilot Patients)

	Specific Condition Outcome Questions	Answers:
2.5a	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: 0% Less than 10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90% 90-100% Unknown

	Additional Feedback	Answers:
2.6a	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.:	[PDF or native format upload.]

Patient Experience Questions

	Customer Satisfaction Questions:	Answers:
3.1a	How do you track overall patient satisfaction?	Please select from the following: Patient survey Complaints filed Anecdotal evidence from providers We do not track this information Other, please specify
3.1b	Please indicate your level of agreement with the following statement: Patients generally report satisfaction with receiving treatment via the Connected Care Pilot program.	Drop-down menu options:  Strongly Disagree Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Somewhat Agree Agree Strongly Agree
3.1c	If tracked, what percentage of patients report satisfaction with receiving treatment via the Connected Care Pilot program?
		Prior Year, if Tracked (in the year prior to the pilot starting)	Reporting Year, if Tracked (in the reporting year since the pilot began)
3.1d	Aggregate patient satisfaction for patients in the Connected Care Pilot program	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
3.1e	Aggregate patient satisfaction across the entire patient population	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

	Health Improvement Questions:	Answers:
3.2a	How did you track patient health satisfaction for your Connected Care Pilot project and if so?	Please select from the following: Patient surveys Complaints filed Anecdotal evidence from providers We do not track this information Other, please specify_____
3.2b	What approximate percentage of patients participating in your Connected Care Pilot project reported an improvement in their health (e.g., reduction in acute incidents) during the reporting period?
3.2c	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:	Answers:
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?	Drop-down menu options: Patient survey Complaints filed Anecdotal evidence from providers We do not track this information Other, please specify _____
3.3b	Have any patients reported any cost savings by receiving treatment via the Connected Care Pilot program during the reporting period?	Drop down menu options: Yes No
		Answers:		Aggregated Estimated Value, if tracked
	Time & Convenience Questions:		Answers:
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?		Drop-down menu options: Patient survey Complaints filed Anecdotal evidence from providers We do not track this information Other, please specify _____
			Answers:		Aggregated Estimate of Time Savings in Hours, If Tracked
3.4b	Receiving treatment via the Connected Care Pilot program enabled your patients to experience a reduction in travel time.		Drop-down menu options:  Strongly Disagree Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Agree Strongly Agree  Did Not Track
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		Drop-down menu options:  Strongly Disagree Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Agree Strongly Agree   Did Not Track
3.4d	Receiving treatment via the Connected Care Pilot program enabled your patients to experience shorter waiting time.		Drop-down menu options:  Strongly Disagree Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Agree Strongly Agree  Did Not Track

	Additional Feedback - Optional	Answers:
3.5a	Please provide any relevant anonymized, aggregated metrics on patient cost savings, reductions in patient travel or time.	[PDF or native format upload]
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	Answers
FR 1.1a	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)	Drop-down options: Yes No
FR 1.1b	Select the following statements that were true for your project.	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.
FR1.1c	Please explain how your project met each of the Connected Care Pilot Program goals.
FR 1.1d	If your project did not meet each of the Connected Care Pilot Program goals, choose the primary reason why not.	Select all that apply:  Lack of provider participation Lack of patient participation Administrative issues Technical issues Other, please specify_________
FR. 1.1e	Did your project meet the goals and objectives that you set for it?	Drop-down options: Yes No
FR 1.1f	If yes, please provide a brief explanation of the goals and objectives that your Connected Care Pilot project met.	[Narrative response]
FR. 1.1g	If your Connected Care Pilot project did not meet the goals and objectives you set for it, please explain why not.

	Lessons Learned	Answers:
FR 1.2a	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?	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
	If the answer to FR 1.2b is Yes, please explain.	Narrative Response
FR 1.2c	Lessons learned concerning the goal of reducing health care costs for patients, facilities, and health care systems.	Drop-down options: Yes No
	If the answer to FR 1.2c is Yes, please explain.	Narrative Response
FR 1.2d	Lessons learned concerning the goal of supporting the trend towards connected care everywhere.	Drop-down options: Yes No
	If the answer to FR 1.2d is Yes, please explain.	Narrative Response
FR 1.2e	Lessons learned concerning the provision and use of connected care services, particularly for low-income and veteran patients.	Drop-down options: Yes No
	If the answer to FR 1.2e is Yes, please explain.	Narrative Response
FR 1.2f	Lessons learned concerning patient retention with respect to connected care services.	Drop-down options: Yes No
	If the answer to FR 1.2f is Yes, please explain.	Narrative Response
FR 1.2g	Lessons learned concerning patient training and how best to address digital literacy challenges.	Drop-down options: Yes No
	If the answer to FR 1.2g is Yes, please explain.	Narrative Response
FR 1.2h	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]

of

[Enter Exact Legal Name of Respondent]

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.

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).

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‑PERM, Paperwork Reduction Act Project (3060‑1271), Washington, DC 20554. 

We will also accept your comments via the Internet if you send them to PRA@fcc.gov. 

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.