Client Contact Form

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0040 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10028 Client Contact Form Form
CMS-10028 CMS-10028.Client Contact Form Client Contact Form Items Straight Text - For 508 Compliant Document - 09 Jan 2013.pdf Form

Information Collection (IC) Details

IC Title:	Client Contact Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: State Health Insurance Assistance Program (SHIP) National Performance Report (SHIP-NPR)	FR Citation: 72 FR 12

Number of Respondents: 11,435	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,269,848	648,625	1,621,223
Annual IC Time Burden (Hours)	189,154	54,052	135,102
Annual IC Cost Burden (Dollars)	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.