OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26)

IC 212601 under ICR 201111-0938-009 · OMB 0938-1148.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10398
Performance Indicator Specification Template BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26)		 Form and Instruction
Form CMS-10398
34 Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children’s Health Insurance Program BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26)		 Form and Instruction
Form CMS-10398
Medicaid Adult Quality Measures Template BUNDLE: Eligibility and Enrollment Performance Indicators (Gen IC #35); Model Application Template (GenIC #34);Medicaid Adult Core Set Measures Reporting Template (GenIC #26)		 Form and Instruction
CMS-10398 Performance Indicator Specification Template
GEN IC#35 - Copy of Performance Indicator Specification Template (7 29 2014) (2).xlsx 		Form and Instruction
CMS-10398 34 Model Application Template and Instructions for State
GenIC #34 - Title-XXI-State-Plan-508final (3).docx 		Form and Instruction
CMS-10398 Medicaid Adult Quality Measures Template
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template (clean).docx 		Form and Instruction
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.xlsx
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk		IC Document
GenIC #26 Medicaid Adult Core Set Measures Reporting Template Supporting Statement Revision.docx
GenIC #26 Medicaid Adult Core Set Measures Reporting Template Supporting Statement Revision		IC Document
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.xlsx
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk		IC Document
GenIC #26 Medicaid Adult Quality Measures Template screenshots.docx
GenIC #26 Medicaid Adult Quality Measures Template screenshots		IC Document
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.xlsx
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk		IC Document
GenIC#26 Medicaid Adult Quality Measures Template Crosswalk of Changes.docx
GenIC#26 Medicaid Adult Quality Measures Template Crosswalk of Changes		IC Document
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk.pdf
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk		IC Document
GenIC#34 - Supporting Statement.docx
GenIC#34 - Supporting Statement		IC Document
GenIC#34 - Supporting Statement.docx
GenIC#34 - Supporting Statement		IC Document
GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement.docx
GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement		IC Document
GenIC#35 - Copy of Performance Indicator Specification Template (7 29 2014) (2).xlsx
GenIC#35 - Copy of Performance Indicator Specification Template		IC Document
GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement.docx
GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement		IC Document
GenIC #35 Supporting Statement.docx
GenIC #35 Supporting Statement		IC Document
GenIC #35 Supporting Statement.docx
GenIC #35 Supporting Statemen		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 and Instruction CMS-10398 Yes Yes Fillable Fileable Signable
Form and Instruction CMS-10398 Yes Yes Fillable Fileable Signable
Form and Instruction CMS-10398 Yes Yes Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module


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 56 0 0 0
Annual IC Time Burden (Hours) 6,205 0 6,205 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
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk 08/07/2014
GenIC #26 Medicaid Adult Core Set Measures Reporting Template Supporting Statement Revision 08/07/2014
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk 08/07/2014
GenIC #26 Medicaid Adult Quality Measures Template screenshots 08/07/2014
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk 08/07/2014
GenIC#26 Medicaid Adult Quality Measures Template Crosswalk of Changes 08/07/2014
GenIC #26 FFY 2014 Medicaid Adult Quality Measures Template Crosswalk 08/07/2014
GenIC#34 - Supporting Statement 08/07/2014
GenIC#34 - Supporting Statement 08/07/2014
GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement 08/07/2014
GenIC#35 - Copy of Performance Indicator Specification Template 08/07/2014
GenIC #35 Eligibility and Enrollment Performace Indicators Supporting Statement 08/07/2014
GenIC #35 Supporting Statement 08/07/2014
GenIC #35 Supporting Statemen 08/07/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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