SHOP Survey

Consumer Research Supporting Outreach for Health Insurance Marketplace

Documents and Forms

Document Name Document Type
Form CMS-10458 SHOP Survey Form and Instruction
CMS-10458 SHOP Survey CMS-10458_SHOP_Tracking_Survey_12_20_12.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	SHOP Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

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-10458	SHOP Survey	CMS-10458_SHOP_Tracking_Survey_12_20_12.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	240	240
Annual IC Cost Burden (Dollars)	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.