Information Collection

Medicare Rural Hospital Flexibility Grant Program Performance Measures

IC 206758 under ICR 201603-0915-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 and Instruction
1 1 Medicare Rural Hospital Flexibility Grant Program Measures OMB 0915-0363 – Revision.xlsx	Form and Instruction
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: Modified

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 and Instruction	1	1	Medicare Rural Hospital Flexibility Grant Program Measures OMB 0915-0363 â Revision.xlsx		Yes	Yes	Fillable Fileable Signable

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	45	0	45
Annual IC Time Burden (Hours)	3,150	-6,570	9,720
Annual IC Cost Burden (Dollars)	0	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.