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Federal forms, ICRs, and supporting documents

Information Collection

Bundle (2 GenICs) - Tobacco Cessation Quitline Expenditures (#25) and Medicaid Adult Core Set Measures Reporting Template (#26)

IC 209053 under ICR 201111-0938-009 · OMB 0938-1148.

Documents and Forms
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Form
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

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Bundle (2 GenICs) - Tobacco Cessation Quitline Expenditures (#25) and Medicaid Adult Core Set Measures Reporting Template (#26)
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10398 (#25) Tobacco Cessation Quitline Expenditures - Participation in Medicaid Administration Federal Financial Participation (FFP) Tobacco Cessation Quitline Expenditures Collection template.docx Yes Yes Fillable Printable
Form and Instruction CMS-10398 (#26) Medicaid Adult Core Set Measures Reporting Template in CARTS Medicaid Adult Core Set Measures Reporting Template.docx Yes Yes Fillable Printable

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 56 0 0 0 0 0
Annual IC Time Burden (Hours) 2,352 0 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Supporting Statement - Tobacco (#25) Tobacco Cessation Quitline Expenditures Supporting Statement.docx 10/24/2013
Supporting Statement - Medicaid Adult Core Set Measures Reporting Template (#26) Medicaid Adult Core Set Measures Reporting Template Supporting Statement.docx 10/24/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.