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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
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:
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
Federal Enterprise Architecture Business Reference Module
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 %
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
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.