Information Collection

State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report

IC 8663 under ICR 200312-0938-005 · OMB 0938-0850.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0850 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	CMS-10028A	Yes	Yes
Form	C	Yes	Yes
Form	B	Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,000,000	999,735	265
Annual IC Time Burden (Hours)	116,747	116,588	159
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.