Qis Implementation Plan And Progress Report Form Page 11
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28QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
23d. If the issuer did not choose health and health care disparities as a topic area in Element 20, but
the QIS does include activities related to addressing health and health care disparities, describe
the activities below. If (1) health and health care disparities is one of the topic areas selected in
Element 20; OR (2) health and health care disparities are not addressed in this QIS,
check
Not Applicable.
(1,000 character limit)
24. Goal(s), Measure(s), and Performance Target(s) to Monitor QIS Progress (Must Pass)
Restate the goal(s) identified in the QIS description (see Element 18).
QIS Goal 1:
(500 character limit)
For this goal, identify at least one (but no more than two) primary measure(s) used to track progress
against the goal.
24a. Measure 1a
Is Measure 1a modified from the most recent QIS submission?
Yes
No
Not Applicable
pg. 11
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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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