SHIP Activity 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⚠️ Notice: This information collection may be referencing outdated material.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 13 SHIP Activity Form Form and Instruction
13 SHIP Activity Form 0040 (13) SHIP Activity Form Team Members Fin 20.xlsx Form and Instruction

Information Collection (IC) Details

IC Title:	SHIP Activity Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	13	SHIP Activity Form	0040 (13) SHIP Activity Form Team Members Fin 20.xlsx		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	8,640	8,640
Annual IC Time Burden (Hours)	1,008	1,008
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.