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

⚠️ Notice: This information collection may be referencing outdated material.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 Public and Media Activity Report Form (PAM) 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 Form and Instruction

Information Collection (IC) Details

IC Title:	Public and Media Activity Report Form (PAM)	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 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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,349	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	76,563	25,386	51,177
Annual IC Time Burden (Hours)	6,380	2,115	4,265
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.