Information Collection

Survey of Health Insurance and Program Participation

IC 192033 under ICR 201002-0607-003 · OMB 0607-0959.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SHIPP Questionnair Survey of Health Insurance and Program Participation	Form
OMB advance letter.wpd	Other-Advance Letter
SHIPP ACS & EXP state-specific plan names.doc	Other-ACS & CPS state-specific plan
SHIPP CPS state-specific plan names.xls	Other-CPS state-specific plan names
TANF names.rtf	Other-TANF names
SHIPP Questionnair SHIPP Questionnaire (CATI Specifications) omb qnnaire.doc	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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	SHIPP Questionnaire (CATI Specifications)	SHIPP Questionnaire (CATI Specifications)	omb qnnaire.doc	Yes	Yes	Fillable Fileable
Other-Advance Letter			OMB advance letter.wpd	No		Paper Only
Other-ACS & CPS state-specific plan names			SHIPP ACS & EXP state-specific plan names.doc	Yes	Yes	Fillable Fileable
Other-CPS state-specific plan names			SHIPP CPS state-specific plan names.xls	Yes	Yes	Fillable Fileable
Other-TANF names			TANF names.rtf	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	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.