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Model Notice
Student Health Insurance Coverage
OMB: 0938-1157
IC ID: 200070
OMB.report
HHS/CMS
OMB 0938-1157
ICR 201111-0938-004
IC 200070
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1157 can be found here:
2022-04-15 - Extension without change of a currently approved collection
2019-07-30 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Model Notice
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Mandatory
CFR Citation:
45 CFR 147.145(d)(1)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
75
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
2,250,000
2,250,000
0
0
0
0
Annual IC Time Burden (Hours)
75,000
75,000
0
0
0
0
Annual IC Cost Burden (Dollars)
14,700
14,700
0
0
0
0
Documents for IC
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.