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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures
Agency IC Tracking Number:
CMCS
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10434 #26
AQM2017-ABA
QSSI-MACPro-PRA-AQM2017-ABA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-AdminScreen
QSSI-MACPro-PRA-AQM2017-AdminScreen.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-AMM
QSSI-MACPro-PRA-AQM2017-AMM.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-BCS
QSSI-MACPro-PRA-AQM2017-BCS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-CBP
QSSI-MACPro-PRA-AQM2017-CBP.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-CCP
QSSI-MACPro-PRA-AQM2017-CCP.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-CCS
QSSI-MACPro-PRA-AQM2017-CCS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-CDF
QSSI-MACPro-PRA-AQM2017-CDF.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-CHL
QSSI-MACPro-PRA-AQM2017-CHL.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-CPA
QSSI-MACPro-PRA-AQM2017-CPA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-FUA
QSSI-MACPro-PRA-AQM2017-FUA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-FUH
QSSI-MACPro-PRA-AQM2017-FUH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-FVA
QSSI-MACPro-PRA-AQM2017-FVA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-HA1C
QSSI-MACPro-PRA-AQM2017-HA1C.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-HPC
QSSI-MACPro-PRA-AQM2017-HPC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-HPCMI
QSSI-MACPro-PRA-AQM2017-HPCMI.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-HVL
QSSI-MACPro-PRA-AQM2017-HVL.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-IET
QSSI-MACPro-PRA-AQM2017-IET.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-MPM
QSSI-MACPro-PRA-AQM2017-MPM.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-MSC
QSSI-MACPro-PRA-AQM2017-MSC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-OHD
QSSI-MACPro-PRA-AQM2017-OHD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-PCO1
QSSI-MACPro-PRA-AQM2017-PC01.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-PC03
QSSI-MACPro-PRA-AQM2017-PC03.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-PCR
QSSI-MACPro-PRA-AQM2017-PCR.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-PPC
QSSI-MACPro-PRA-AQM2017-PPC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-PQI01
QSSI-MACPro-PRA-AQM2017-PQI01.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-PQI05
QSSI-MACPro-PRA-AQM2017-PQI05.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-PQI08
QSSI-MACPro-PRA-AQM2017-PQI08.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-PQI15
QSSI-MACPro-PRA-AQM2017-PQI15.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-SAA
QSSI-MACPro-PRA-AQM2017-SAA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2017-SSD
QSSI-MACPro-PRA-AQM2017-SSD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-ABA
QSSI-MACPro-PRA-AQM2018-ABA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-AdminScreen
QSSI-MACPro-PRA-AQM2018-AdminScreen.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-AMM
QSSI-MACPro-PRA-AQM2018-AMM.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-AMR
QSSI-MACPro-PRA-AQM2018-AMR.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-BCS
QSSI-MACPro-PRA-AQM2018-BCS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-CBP
QSSI-MACPro-PRA-AQM2018-CBP.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-CCP
QSSI-MACPro-PRA-AQM2018-CCP.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-CCS
QSSI-MACPro-PRA-AQM2018-CCS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-CCW
QSSI-MACPro-PRA-AQM2018-CCW.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-CHL
QSSI-MACPro-PRA-AQM2018-CHL.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-COB
QSSI-MACPro-PRA-AQM2018-COB.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-CPA
QSSI-MACPro-PRA-AQM2018-CPA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-FUA FUM
QSSI-MACPro-PRA-AQM2018-FUA_FUM.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-FUH
QSSI-MACPro-PRA-AQM2018-FUH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-FVA
QSSI-MACPro-PRA-AQM2018-FVA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-HA1C
QSSI-MACPro-PRA-AQM2018-HA1C.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-HPC
QSSI-MACPro-PRA-AQM2018-HPC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-HPCMI
QSSI-MACPro-PRA-AQM2018-HPCMI.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-HVL
QSSI-MACPro-PRA-AQM2018-HVL.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-IET
QSSI-MACPro-PRA-AQM2018-IET.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-MPM AD
QSSI-MACPro-PRA-AQM2018-MPM-AD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-MSC
QSSI-MACPro-PRA-AQM2018-MSC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-OHD
QSSI-MACPro-PRA-AQM2018-OHD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-PC01 AD
QSSI-MACPro-PRA-AQM2018-PC01-AD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-PC03 AD
QSSI-MACPro-PRA-AQM2018-PC03-AD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-PCR AD
QSSI-MACPro-PRA-AQM2018-PCR-AD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-PPC AD
QSSI-MACPro-PRA-AQM2018-PPC-AD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-PQI01
QSSI-MACPro-PRA-AQM2018-PQI01.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-PQI05
QSSI-MACPro-PRA-AQM2018-PQI05.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-PQI08
QSSI-MACPro-PRA-AQM2018-PQI08.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-PQI15
QSSI-MACPro-PRA-AQM2018-PQI15.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-SSA AD
QSSI-MACPro-PRA-AQM2018-SAA-AD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
AQM2018-SSD AD
QSSI-MACPro-PRA-AQM2018-SSD-AD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-ADD
QSSI-MACPro-PRA-CQM2017-ADD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-AdminScreen
QSSI-MACPro-PRA-CQM2017-AdminScreen.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-AMB
QSSI-MACPro-PRA-CQM2017-AMB.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-APC
QSSI-MACPro-PRA-CQM2017-APC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-APP
QSSI-MACPro-PRA-CQM2017-APP.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-AUD
QSSI-MACPro-PRA-CQM2017-AUD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-AWC
QSSI-MACPro-PRA-CQM2017-AWC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-BHRA
QSSI-MACPro-PRA-CQM2017-BHRA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-CAP
QSSI-MACPro-PRA-CQM2017-CAP.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-CHL
QSSI-MACPro-PRA-CQM2017-CHL.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-CIS
QSSI-MACPro-PRA-CQM2017-CIS.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-CLABSI
QSSI-MACPro-PRA-CQM2017-CLABSI.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-CPC
QSSI-MACPro-PRA-CQM2017-CPC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-DEV
QSSI-MACPro-PRA-CQM2017-DEV.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-FPC
QSSI-MACPro-PRA-CQM2017-FPC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-FUH
QSSI-MACPro-PRA-CQM2017-FUH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-IMA
QSSI-MACPro-PRA-CQM2017-IMA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-LBW
QSSI-MACPro-PRA-CQM2017-LBW.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-MMA
QSSI-MACPro-PRA-CQM2017-MMA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-PC02
QSSI-MACPro-PRA-CQM2017-PC02.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-PDENT
QSSI-MACPro-PRA-CQM2017-PDENT.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-PPC
QSSI-MACPro-PRA-CQM2017-PPC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-SEAL
QSSI-MACPro-PRA-CQM2017-SEAL.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-SRA
QSSI-MACPro-PRA-CQM2017-SRA.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-StateSpecific
QSSI-MACPro-PRA-CQM2017-StateSpecific.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-W15
QSSI-MACPro-PRA-CQM2017-W15.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-W34
QSSI-MACPro-PRA-CQM2017-W34.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2017-WCC
QSSI-MACPro-PRA-CQM2017-WCC.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-ADD-CH
QSSI-MACPro-PRA-CQM2018-ADD-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-AdminScreen
QSSI-MACPro-PRA-CQM2018-AdminScreen.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-AMB-CH
QSSI-MACPro-PRA-CQM2018-AMB-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-AMR-CH
QSSI-MACPro-PRA-CQM2018-AMR-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-APC-CH
QSSI-MACPro-PRA-CQM2018-APC-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-APP-CH
QSSI-MACPro-PRA-CQM2018-APP-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-AUD-CH
QSSI-MACPro-PRA-CQM2018-AUD-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-AWC-CH
QSSI-MACPro-PRA-CQM2018-AWC-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-CAP-CH
QSSI-MACPro-PRA-CQM2018-CAP-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-CCP-CH
QSSI-MACPro-PRA-CQM2018-CCP-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-CCW-CH
QSSI-MACPro-PRA-CQM2018-CCW-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-CDF-CH
QSSI-MACPro-PRA-CQM2018-CDF-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-CHL-CH
QSSI-MACPro-PRA-CQM2018-CHL-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-CIS-CH
QSSI-MACPro-PRA-CQM2018-CIS-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-CLABSI-CH
QSSI-MACPro-PRA-CQM2018-CLABSI-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-CPC-CH
QSSI-MACPro-PRA-CQM2018-CPC-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-DEV-CH
QSSI-MACPro-PRA-CQM2018-DEV-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-FUH-CH
QSSI-MACPro-PRA-CQM2018-FUH-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-IMA-CH
QSSI-MACPro-PRA-CQM2018-IMA-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-LBW-CH
QSSI-MACPro-PRA-CQM2018-LBW-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-PC02-CH
QSSI-MACPro-PRA-CQM2018-PC02-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-PDENT-CH
QSSI-MACPro-PRA-CQM2018-PDENT-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-PPC-CH
QSSI-MACPro-PRA-CQM2018-PPC-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-SEAL-CH
QSSI-MACPro-PRA-CQM2018-SEAL-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-W15-CH
QSSI-MACPro-PRA-CQM2018-W15-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-W34-CH
QSSI-MACPro-PRA-CQM2018-W34-CH.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10434 #26
CQM2018-WCC-CH
QSSI-MACPro-PRA-CQM2018-WCC-CH.pdf
Yes
Yes
Fillable Fileable
Instruction
QSSI-MACPro-PRA-AdditionalNotes.pdf
Yes
Yes
Fillable Fileable
Instruction
QSSI-MACPro-PRA-AQM-MIH-DefOfPopulation.pdf
Yes
Yes
Fillable Fileable
Instruction
QSSI-MACPro-PRA-CombinedRates.pdf
Yes
Yes
Fillable Fileable
Instruction
QSSI-MACPro-PRA-DateRange.pdf
Yes
Yes
Fillable Fileable
Instruction
QSSI-MACPro-PRA-CQM_DefOfPopulation.pdf
Yes
Yes
Fillable Fileable
Instruction
QSSI-MACPro-PRA-NotReporting.pdf
Yes
Yes
Fillable Fileable
Instruction
QSSI-MACPro-PRA-OPM.pdf
Yes
Yes
Fillable Fileable
Instruction
QSSI-MACPro-PRA-StatusOfData.pdf
Yes
Yes
Fillable Fileable
Instruction
QSSI-MACPro-PRA-TechnicalAssistance.pdf
Yes
Yes
Fillable Fileable
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
224
0
224
0
0
0
Annual IC Time Burden (Hours)
8,960
0
8,960
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Generic Supporting Statement
26 - Supporting Statement (2019 version 2).docx
07/11/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.