Information Collection

GenIC #26 (Extension w/o change): Medicaid Adult Core Set Measures Reporting Template

IC 229683 under ICR 201712-0938-019 · 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⚠️ Notice: This information collection may be referencing outdated material.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 #26 GenIC #26 (Extension w/o change): Medicaid Adult Core Set Measures Reporting Template	Form and Instruction
CMS-10398 #26 Medicaid Adult Core Set Measures Template 26 - GenIC _26 FFY 2014 Medicaid Adult Quality Measures Template (clean).docx	Form and Instruction
26 - Revised Supporting Statement Medicaid Adult Core Set Measures.docx #26 - Supporting Statement	IC Document

IC Title:

GenIC #26 (Extension w/o change): Medicaid Adult Core Set Measures Reporting Template

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 and Instruction	CMS-10398 #26	Medicaid Adult Core Set Measures Template	26 - GenIC _26 FFY 2014 Medicaid Adult Quality Measures Template (clean).docx		Yes	Yes	Fillable Fileable

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	2,240	2,240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#26 - Supporting Statement	26 - Revised Supporting Statement Medicaid Adult Core Set Measures.docx	01/08/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.