Information Collection

Client Contact Form

IC 193277 under ICR 201606-0985-003 · OMB 0985-0040.

⚠️ Notice: This information collection may be referencing outdated material.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 1 Client Contact Form Form
1 Client Contact Form Client Contact Form Items Straight Text - For 508 Compliant Document - 0....rtf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Client Contact Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Client Contact Form	Client Contact Form Items Straight Text - For 508 Compliant Document - 0....rtf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: State Health Insurance Assistance Program (SHIP) National Performance Report (SHIP-NPR)	FR Citation: 72 FR 12

Number of Respondents: 11,435	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	Previously Approved
Annual Number of Responses for this IC	3,602,025	1,332,177	2,269,848
Annual IC Time Burden (Hours)	318,000	128,846	189,154
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.