SHIP/MIPPA Group Outreach Education Form

State Health Insurance Assistance Program (SHIP) Client Contact Forms

⚠️ Notice: This information collection may be referencing outdated material.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 4 SHIP/MIPPA Group Outreach Education Form Form and Instruction
4 Group Outreach and Education Form 0040 (4) Group Outreach Education Form Fin 20.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	SHIP/MIPPA Group Outreach Education Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	4	Group Outreach and Education Form	0040 (4) Group Outreach Education Form Fin 20.pdf		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: 3,750	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	56,250	7,250	49,000
Annual IC Time Burden (Hours)	3,750	1,586	2,164
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.