Qis Implementation Plan And Progress Report Form Page 10
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28QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
23. Activity(ies) that Will Be Conducted to Implement the QIS (Must Pass)
Is the activity(ies) modified from the most recent QIS submission?
Yes
No
Not Applicable
23a. List the activities that will be implemented to achieve the identified goals.
(1,000 character limit)
23b. Describe how the activities relate to the selected market-based incentive (see Element 19).
(1,000 character limit)
23c. Describe how the activities relate to the topic area(s) selected (see Element 20).
(1,000 character limit)
pg. 10
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time
required to complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
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