Matrix Column

Shared NH/SB Subsets

XX - Inactivation

13 items x 12 applies - 1 not submitted

A \u2014 Identification Information

X \u2014 Correction Request

Type of Provider (A0200 on existing record to be

Name of Resident (A0500 on existing record to be

Sex (A0810 on existing record to be modified/inactivated)

Birth Date (A0900 on existing record to be

Social Security Number (A0600A on existing record to be

Type of Assessment/Tracking (A0310 on existing record

Date on Existing Record to Be Modified/Inactivated –

Correction Attestation Section

Reasons for Modification

Reasons for Inactivation

RN Assessment Coordinator Attestation of Completion

Z \u2014 Assessment Administration

Signatures of Persons Completing the Assessment or

- Not submitted to iQIES ›