SHIP/MIPPA Team Member Form

State Health Insurance Assistance Program (SHIP) Client Contact Forms

OMB: 0985-0040

IC ID: 193279

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

SHIP/MIPPA Team Member 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 NA SIRS Team Member Form 0040 SIRS Team Member Form 2023 Ins 5.docx Yes Yes Fillable Fileable

Community and Social Services Social Services

 

216 0
   
State, Local, and Tribal Governments
 
   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 16,200 0 0 0 0 16,200
Annual IC Time Burden (Hours) 1,008 0 0 0 0 1,008
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

© 2024 OMB.report | Privacy Policy