SHOP - Employee

Data Collection to Support Eligibility Determinations and Enrollment for Employees in the Small Business Health Options Program

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.