Information Collection

SHIP/MIPPA Media Outreach Education Form

IC 193278 under ICR 202310-0985-004 · OMB 0985-0040.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SHIP/MIPPA Media Outreach Education Form	Form and Instruction
STARS MOE 0040 STARS MOE 2023 Ins 1.docx	Form and Instruction
STARS MOE 0040 STARS MOE 2023 Ins 1.docx	Form and Instruction

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	STARS MOE	0040 STARS MOE 2023 Ins 1.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,750

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	56,250	56,250
Annual IC Time Burden (Hours)	3,750	3,750
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.