Public and Media Activity Report Form (PAM)

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

OMB: 0985-0040

IC ID: 193278

Information Collection (IC) Details

View Information Collection (IC)

Public and Media Activity Report Form (PAM)
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10028 Public and Media Activity Form (PAM) Public and Media Form Items Straight Text - For 508 Compliant Document - 09 Jan 2013.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

6,349 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 76,563 0 25,386 0 0 51,177
Annual IC Time Burden (Hours) 6,380 0 2,115 0 0 4,265
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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