Information Collection

Medicare Rural Hospital Flexibility Grant Program Performance Measures

IC 206758 under ICR 202509-0915-003 · OMB 0915-0363.

Documents and Forms

Document Name Document Type
Form A Medicare Rural Hospital Flexibility Grant Program Performance Measures Form
Form A Flex Program Areas and Outcome Measures Medicare Rural Hospital Flexibility Grant Program Performance Measures Form
Form B U2W Flex Program Sample Data Collection Medicare Rural Hospital Flexibility Grant Program Performance Measures Form
A Flex Program Areas and Outcome Measures Attachment A_Flex Program Areas and Outcome Measures.docx Form
A Flex Program Areas and Outcome Measures Attachment A_Flex Program Areas and Outcome Measures.docx Form
B U2W Flex Program Sample Data Collection Attachment B_U2W Flex Program Sample Data Collection.xlsx Form
B U2W Flex Program Sample Data Collection Attachment B_U2W Flex Program Sample Data Collection.xlsx Form

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	A	Flex Program Areas and Outcome Measures	Attachment A_Flex Program Areas and Outcome Measures.docx		Yes	Yes	Fillable Fileable
Form	B	U2W Flex Program Sample Data Collection	Attachment B_U2W Flex Program Sample Data Collection.xlsx		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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	45	0	45
Annual IC Time Burden (Hours)	2,475	-675	3,150
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.

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