Medicare Rural Hospital Flexibility Grant Program Performance Measures

Forms and Documents

Document Name	Status
Form 1 Medicare Rural Hospital Flexibility Grant Program Performance Measures Form	New
Attachment C_PIMSOMBmeasures.xlsx Supplementary Document	2013-04-25
Attachment B_HRSA-5-H54-13-001 Flex NCC Progress Reportfinal with measures 02272013.docx Supplementary Document	2013-04-25
Attachment A_NOSORH flex measures comment 2-28-13.pdf Supplementary Document	2013-04-25
Supporting Statement Flex - with edits.docx Supporting Statement A	2013-04-25

IC Document Collections

IC ID	Document Title	Status
206758	Medicare Rural Hospital Flexibility Grant Program Performance Measures Form	New

ICR Details

OMB Control No: 0915-0363	ICR Reference No: 201305-0915-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No: 19326
Title: Medicare Rural Hospital Flexibility Grant Program Performance Measures
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/02/2013
	Date Received in OIRA: 05/01/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	36 Months From Approved
Responses	45	0	0
Time Burden (Hours)	9,720	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The purpose of the performance measures is to provide standardized useful information about funded activities, to monitor grantee progress and to demonstrate program impact. The information will be gather from the 45 Medicare Rural Hospital Flexibility Grant Program recipients and will be used to inform program and the grantees of the effectiveness of the program activities.

---

Authorizing Statute(s): US Code: 42 USC 711 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 77079	12/31/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 24755	04/26/2013
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Rural Hospital Flexibility Grant Program Performance Measures	1	Medicare Rural Hospital Flexibility Grant Program Performance Measures

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	45	0	0	45	0	0
Annual Time Burden (Hours)	9,720	0	0	9,720	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection

---

Annual Cost to Federal Government: $44,528

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/01/2013

---