Information Collection

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

IC 8663 under ICR 200704-0938-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10028-A State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report	Form
CMS-10028-A Client Contact InstManual 12.06.pdf	Instruction
CMS-10028-B PAM instructions 12.06.pdf	Instruction
CMS-10028-C Resource Rpt Form Inst 12.06.doc	Instruction
CMS-10028-A State Health Insurance Assistance Program (SHIP) Client CMS-10028-A Client Contact 12.06.pdf	Form
CMS-10028-C State Health Insurance Assistance Program (SHIP) Resourc CMS-10028-C Resource12.06.pdf	Form
CMS-10028-B State Health Insurance Assistance Program (SHIP) Public CMS-10028-B PAM_12.06.pdf	Form

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: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.510

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10028-A	State Health Insurance Assistance Program (SHIP) Client Contact Form	CMS-10028-A Client Contact 12.06.pdf	Yes	Yes	Paper Only
Instruction			CMS-10028-A Client Contact InstManual 12.06.pdf	Yes	Yes	Paper Only
Form	CMS-10028-C	State Health Insurance Assistance Program (SHIP) Resource Report Form	CMS-10028-C Resource12.06.pdf	Yes	Yes	Paper Only
Form	CMS-10028-B	State Health Insurance Assistance Program (SHIP) Public and Media Activity Form	CMS-10028-B PAM_12.06.pdf	Yes	Yes	Paper Only
Instruction			CMS-10028-B PAM instructions 12.06.pdf	Yes	Yes	Paper Only
Instruction			CMS-10028-C Resource Rpt Form Inst 12.06.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

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

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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