Information Collection

SHOP - Employee

IC 205690 under ICR 201302-0938-002 · OMB 0938-1194.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1194 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10438 SHOP - Employee	Form and Instruction
CMS-10438 Appendix_A-SHOP_Employee_List_of_Questions CMS-10438-AppendixA_SHOP_Employee 5-10-13.docx	Form and Instruction
CMS-10438 Appendix_B-SHOP_Employee_Application SHOP Application forEmployees.052313-508.pdf	Form and Instruction

IC Title:

SHOP - Employee

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.730

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10438	Appendix_B-SHOP_Employee_Application	SHOP Application forEmployees.052313-508.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10438	Appendix_A-SHOP_Employee_List_of_Questions	CMS-10438-AppendixA_SHOP_Employee 5-10-13.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 888,888

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	888,888	888,888
Annual IC Time Burden (Hours)	180,178	180,178
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.