Information Collection

Medicare Rural Hospital Flexibility Grant Program Performance Measures

IC 206758 under ICR 201905-0915-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 1 Medicare Rural Hospital Flexibility Grant Program Performance Measures Form
1 Attachment C Flex screenshots.docx Attachment C Flex screenshots.docx Form
Attachment E Flex Reporting Instructions.pdf Attachment E - FLEX Reporting Instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Attachment C Flex screenshots.docx	Attachment C Flex screenshots.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: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	45	45
Annual IC Time Burden (Hours)	3,150	3,150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment E - FLEX Reporting Instructions	Attachment E Flex Reporting Instructions.pdf	05/22/2019

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