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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #26 (Extension) - Medicaid Adult and Child Core Set Measures
Agency IC Tracking Number:
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
Other-PRA Disclosure Statement
PRA Disclosure Statement 082919 (rev 08-30-2019).pdf
No
Printable Only
Form and Instruction
390-CQM 2018-CCW-CH-PRA-D
Contraceptive Care – All Women Ages 15-20 (CCW-CH)
CQM2018 QSSI-CCW-CH.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
385-CQM 2018-ADD-CH-PRA-D
CQM 2018 - Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH) Core Measure PRA Document
#26 CQM2018.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
385-CQM 2018-ADD-CH-PRA-D
CQM 2018 - Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH) Core Measure PRA Document
#26 CQM2017.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
429-AQM 2018 ABA-AD PRA-D
AQM 2018 – Adult Body Mass Index Assessment (ABA) Core Measure PRA document
AQM2017.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
245-QSSI-MACPro-PRA-AdditionalNotes-D
AQM, CQM & MIH - Additional Notes PRA document
#26 Common Questions.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 %
Requested
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
GenIC Supporting Statement
26 - Supporting Statement (2019 version 2).docx
08/30/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.