SHIP/MIPPA Group Outreach Education Form

State Health Insurance Assistance Program (SHIP) Client Contact Forms

OMB: 0985-0040

IC ID: 232707

Documents and Forms
Information Collection (IC) Details

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SHIP/MIPPA Group Outreach Education Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 4 Group Outreach and Education Form 0040 (4) Group Outreach Education Form Fin 20.pdf Yes Yes Fillable Fileable

Community and Social Services Social Services

 

3,750 0
   
Individuals or Households
 
   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 56,250 0 7,250 0 0 49,000
Annual IC Time Burden (Hours) 3,750 0 1,586 0 0 2,164
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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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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