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.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 (#25) Bundle (2 GenICs) - Tobacco Cessation Quitline Expenditures (#25) and Medicaid Adult Core Set Measures Reporting Template (#26)	Form
CMS-10398 (#25) Tobacco Cessation Quitline Expenditures - Participation Tobacco Cessation Quitline Expenditures Collection template.docx	Form
CMS-10398 (#26) Medicaid Adult Core Set Measures Reporting Template in C Medicaid Adult Core Set Measures Reporting Template.docx	Form and Instruction
Tobacco Cessation Quitline Expenditures Supporting Statement.docx Supporting Statement - Tobacco (#25)	IC Document
Medicaid Adult Core Set Measures Reporting Template Supporting Statement.docx Supporting Statement - Medicaid Adult Core Set Measures Reporting Template (#26)	IC Document

IC Title:

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

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

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	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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	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

Documents for IC

table that charts IC Documents
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.