Information Collection Request

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

ICR 201006-0938-006 · OMB 0938-0850 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10028-A State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report Form Removed Available
Form CMS-10028 RESOURCE REPORT Form New Available
Form CMS-10028 Public and Media Activity Report Form (PAM) Form New Available
Form CMS-10028 Client Contact Form Form New Available
CMS-10028 Attachment C.doc Supplementary Document Uploaded 2010-05-19 Available
CMS-10028 Attachment B.doc Supplementary Document Uploaded 2010-05-19 Available
CMS-10028 Attachment A-REVISED.doc Supplementary Document Uploaded 2010-05-19 Available
CMS-10028.Supporting Statement - Part A.doc Supporting Statement A Uploaded 2010-05-19 Available

IC Document Collections

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
07/31/2013 36 Months From Approved 07/31/2010
1,672,454 0 1,056,000
139,475 0 87,965
0 0 0





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 1,672,454 1,056,000 0 -1,056,000 1,672,454 0
Annual Time Burden (Hours) 139,475 87,965 0 -87,965 139,475 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No