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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.