SHOP - Employer

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1193 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10439 SHOP - Employer Form and Instruction
CMS-10439 Appendix A SHOP Employer Questionnaire CMS-10439.Appendix_A (SHOP- Employer)-5-9-13.docx Form and Instruction
CMS-10439 Appendix B SHOP Employer Application SHOP ApplicationforEmployers.052313-508.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	SHOP - Employer	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 155.725 45 CFR 155.730 45 CFR 155.410

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10439	Appendix A SHOP Employer Questionnaire	CMS-10439.Appendix_A (SHOP- Employer)-5-9-13.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10439	Appendix B SHOP Employer Application	SHOP ApplicationforEmployers.052313-508.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 177,777	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	177,777	177,777
Annual IC Time Burden (Hours)	36,089	36,089
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.