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OMB Control No: 0915-0363	ICR Reference No: 202509-0915-003
Status: Received in OIRA	Previous ICR Reference No: 202208-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No: 19326
Title: Medicare Rural Hospital Flexibility Grant Program Performance Measures
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 09/22/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2025
Responses	45	45
Time Burden (Hours)	2,475	3,150
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	45	45	0
Annual Time Burden (Hours)	2,475	3,150	-675
Annual Cost Burden (Dollars)	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The estimated burden per respondent is based on an average of the time needed for completion. This was determined by current respondents to this submission providing the amount of time it would take for them to complete a form in this manner. Different respondents were engaged and this number represents the average of those times. This is a decrease in the estimated burden hours from the previous ICR, as information will be consolidated into one location, rather than entities needing to maintain data in multiple locations to report back to HRSA.

Annual Cost to Federal Government: $236,264

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. 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? No

Agency Contact: Laura Cooper 301 443-2126 lcooper@hrsa.gov