Information Collection

GenIC #35 Revised (Eligibility and Enrollment Performance Indicators)

IC 281674 under ICR 202607-0938-014 · OMB 0938-1148.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form GenIC #35 Eligibility and Enrollment Performance Indicators Template GenIC #35 Revised (Eligibility and Enrollment Performance Indicators)	Form and Instruction
PI-data-dictionary_clean_20260513.pdf	Other-Performance Indicators Data Di
GenIC #35 Eligibility and Enrollment Performance Indicators Templa PI GEN IC_35 Specification Template 20260513.xlsx	Form and Instruction
GenIC 35 - Generic Supporting Statement (CMS-2454-IFC version 6).docx Generic Supporting Statement	IC Document
PI-data-dictionary_tracked_20260513.pdf Redline - Performance Indicators Data Dictionary	IC Document
PI Crosswalk_All_Data_Elements_20260513.xlsx Crosswalk - All Data Elements	IC Document
PI Crosswalk_New_Data_Elements_20260513.xlsx Crosswalk - New Data Elements	IC Document
PI CE Metrics Mock-up for SDIS Tool_20260513.pptx Mock Up - State Data Information System (SDIS) Tool	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

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
Other-Performance Indicators Data Dictionary					No		Printable Only
Form and Instruction	GenIC #35				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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	2,324	2,324
Annual IC Time Burden (Hours)	11,352	11,352
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		07/28/2026
Redline - Performance Indicators Data Dictionary		07/28/2026
Crosswalk - All Data Elements		07/28/2026
Crosswalk - New Data Elements		07/28/2026
Mock Up - State Data Information System (SDIS) Tool		07/28/2026

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

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