SMP Media Outreach & Education

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⚠️ Notice: This information collection may be referencing outdated material.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 7 SMP Media Outreach & Education Form and Instruction
7 SMP Media Outreach and Education Form 0040 (7) SMP SIRS_Media_Outreach_and_Education_Fom Fin 20.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	SMP Media Outreach & Education	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	7	SMP Media Outreach and Education Form	0040 (7) SMP SIRS_Media_Outreach_and_Education_Fom 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: 216	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,936	9,936
Annual IC Time Burden (Hours)	662	662
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.