State Health Insurance Assistance Program (SHIP) Client Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8662	State Health Insurance Assistance Program (SHIP) Client Report	Form	Migrated

ICR Details

OMB Control No: 0938-0850	ICR Reference No: 200108-0938-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: State Health Insurance Assistance Program (SHIP) Client Report
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/30/2001
	Date Received in OIRA: 08/23/2001
Terms of Clearance: Approved for use through 12/2003 under the following conditions: 1) CMS amends the race/ethnicity categories of this instrument to comply with OMB Directive 15. OMB appreciates CMS efforts to coordinate this instrument with NAPIS and other state instruments however, delaying compliance with the Directive may be more confusing for the SHIP program in the longer term; 2) CMS amends the instrument and instructions to clarify that interviewers may only "guess" a respondent's race/ethnicity during the course of an in-person encounter; 3) CMS adds a check box reflecting that a race/ethnicity designation is based upon an interviewer's "guess"; 4) CMS works with its contractor ABT to further evaluate the practical utility of these race/ethnicity data and provides an analysis in the next OMB submission; and 5) in addition, the next submission for OMB review reevaluates opportunities for coordinating this instrument with AoA's NAPIS collection. OMB believes that consideration of an alternative, combined collection is worth additional consideration since it may reduce burdens on half of the community-level sponsoring organizations.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2004	02/29/2004
Responses	265	0	0
Time Burden (Hours)	159	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The State Health Insurance Assistance Program (SHIP) Client Contact Form will be completed by SHIP counselors at each counseling event in order to collect SHIP performance data. This data will then be accumulated and analyzed to measure SHIP performance.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
State Health Insurance Assistance Program (SHIP) Client Report	HCFA-10028A-C

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	265	0	0	265	0	0
Annual Time Burden (Hours)	159	0	0	159	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/23/2001

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