Information Collection

SHOP - Employee

IC 205690 under ICR 201603-0938-018 · OMB 0938-1194.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10438 SHOP - Employee	Form and Instruction
CMS-10438 - Appendix B - SHOP Employee Enrollment User Guide (December 2015).pdf	Instruction
CMS-10438 Appendix_A-SHOP_Employee_List_of_Questions CMS-10438 - Appendix A_SHOP Online Application Questions Employees.pdf	Form and Instruction

IC Title:

SHOP - Employee

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.730

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10438	Appendix_A-SHOP_Employee_List_of_Questions	CMS-10438 - Appendix A_SHOP Online Application Questions Employees.pdf		Yes	Yes	Fillable Fileable
Instruction			CMS-10438 - Appendix B - SHOP Employee Enrollment User Guide (December 2015).pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	60,000	-828,888	888,888
Annual IC Time Burden (Hours)	60,000	-120,178	180,178
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.