Information Collection

Medicare Rural Hospital Flexibility Grant Program Performance Measures

IC 206758 under ICR 201305-0915-001 · OMB 0915-0363.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0363 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Medicare Rural Hospital Flexibility Grant Program Performance Measures	Form
1 Medicare Rural Hospital Flexibility Grant Program Perfor Flexmeasures attachment C.docx	Form
Attachment A_NOSORH flex measures comment 2-28-13.pdf public comments	IC Document
Attachment B_HRSA-5-H54-13-001 Flex NCC Progress Reportfinal with measures 02272013.docx Instructions	IC Document
Attachment C_PIMSOMBmeasures.xlsx spreadsheet version of the measures	IC Document

IC Title:

Medicare Rural Hospital Flexibility Grant Program Performance Measures

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Medicare Rural Hospital Flexibility Grant Program Performance Measures	Flexmeasures attachment C.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	45	45
Annual IC Time Burden (Hours)	9,720	9,720
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
public comments	Attachment A_NOSORH flex measures comment 2-28-13.pdf	04/25/2013
Instructions	Attachment B_HRSA-5-H54-13-001 Flex NCC Progress Reportfinal with measures 02272013.docx	04/25/2013
spreadsheet version of the measures	Attachment C_PIMSOMBmeasures.xlsx	04/25/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.