Client Contact Form

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

OMB: 0985-0040

IC ID: 193277

Information Collection (IC) Details

View Information Collection (IC)

Client Contact Form
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10028 CMS-10028.Client Contact Form Client Contact Form Items Straight Text - For 508 Compliant Document - 09 Jan 2013.pdf Yes Yes Fillable Fileable Signable

Health Health Care Services

State Health Insurance Assistance Program (SHIP) National Performance Report (SHIP-NPR)  72 FR 12

11,435 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved 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 2,269,848 0 648,625 0 0 1,621,223
Annual IC Time Burden (Hours) 189,154 0 54,052 0 0 135,102
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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