Information Collection

National Beneficiary Survey State Health Insurance Assistance Program (SHIP)

IC 225703 under ICR 201702-0985-002 · OMB 0985-0057.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0057 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 SHIP Phone Counseling Survey National Beneficiary Survey State Health Insurance Assistance Program (SHIP)	Form
1 SHIP Phone Counseling Survey Review-ACL_SHIP-Phone-Survey.pdf	Form

IC Title:

National Beneficiary Survey State Health Insurance Assistance Program (SHIP)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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	1				Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,350

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,350	1,350
Annual IC Time Burden (Hours)	180	180
Annual IC Cost Burden (Dollars)	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.

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