Information Collection

Medicare Rural Hospital Flexibility Grant Program Performance Measures

IC 206758 under ICR 202208-0915-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Flex program - reporting instructions.pdf	Instruction
Flex program - reporting instructions.pdf	Instruction
1 Data Collection Instruments Flex Program 0915-0363 Data Collection Instruments_Flex Program 0915-0363.pdf	Form
1 Data Collection Instruments Flex Program 0915-0363 Data Collection Instruments_Flex Program 0915-0363.pdf	Form

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	Data Collection Instruments Flex Program 0915-0363	Data Collection Instruments_Flex Program 0915-0363.pdf		Yes	Yes	Fillable Fileable
Instruction			Flex program - reporting instructions.pdf		Yes	No	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	Change Due to Potential Violation of the PRA
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
No associated records found

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