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

Forms and Documents

Document Name	Status
Form CMS-10028-A State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report Form	Modified
SHIP Reporting (0938-0850).doc Supplementary Document	2007-06-18
TERMS of CLEARANCE.doc Supplementary Document	0000-00-00
CMS-10028 2006 Statement of Supporting Statement.doc Supporting Statement A	0000-00-00

IC Document Collections

IC ID	Document Title	Status
8663	State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report Form	Modified

ICR Details

OMB Control No: 0938-0850	ICR Reference No: 200704-0938-003
Status: Historical Active	Previous ICR Reference No: 200312-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: State Health Insurance Assistance Program (SHIP) Client Contact Form, Pubic and Media Activity Form, and Resource Report Form.
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/19/2007
	Date Received in OIRA: 04/15/2007
Terms of Clearance: CMS will continue to update OMB on progress toward coordination with AoA's NAPIS system.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2010	36 Months From Approved	06/30/2007
Responses	1,056,000	0	1,000,000
Time Burden (Hours)	87,965	0	116,747
Cost Burden (Dollars)	0	0	0

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Abstract: State Health Insurance Assistance Program (SHIP) Client Contact Form and Public and Media Activity (PAM) Form will be completed by SHIP staff and counselors at each counseling and outreach event in order to collect SHIP performance data. Resource Report data are collected the State SHIP program staff. This data will then be accumulated and analyzed to measure SHIP performance.

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Authorizing Statute(s): US Code: 42 USC 1395b-4 Name of Law: Health insurance information, counseling, and assistance grants
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 1536	01/12/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 15139	03/30/2007
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report	CMS-10028-A, CMS-10028-C, CMS-10028-B	State Health Insurance Assistance Program (SHIP) Client Contact Form ,   State Health Insurance Assistance Program (SHIP) Resource Report Form ,   State Health Insurance Assistance Program (SHIP) Public and Media Activity Form

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ICR Summary 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	1,056,000	1,000,000	0	0	56,000	0
Annual Time Burden (Hours)	87,965	116,747	0	0	-28,782	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

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: $400,000

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: 04/15/2007

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