Information Collection Request
State Health Insurance Assistance Program (SHIP) Client Contact Forms
ICR 202310-0985-004 · OMB 0985-0040 · Received in OIRA
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 SHIP Activity Form |
Form and Instruction | Modified | Repair queued |
| SIRS Individual Interaction-Complex Form |
Form and Instruction | Modified | Repair queued |
| SIRS Team Member Form |
Form and Instruction | Modified | Repair queued |
| SMP Team Member Form |
Form and Instruction | Modified | Repair queued |
| SMP Individual Interaction-Basic |
Form and Instruction | Modified | Repair queued |
| SMP Group Outreach & Education |
Form and Instruction | Modified | Repair queued |
| SMP Media Outreach & Education |
Form and Instruction | Modified | Repair queued |
| SHIP/MIPPA Group Outreach Education Form |
Form and Instruction | Modified | Repair queued |
| SHIP/MIPPA Team Member Form |
Form and Instruction | Modified | Repair queued |
| SHIP/MIPPA Media Outreach Education Form |
Form and Instruction | Modified | Repair queued |
| SHIP/MIPPA Beneficiary Client Form |
Form and Instruction | Modified | Repair queued |
 0040 OMB SS Dec 2023 - 12.18.23 PRA KJG Edits.docx |
Supporting Statement A | Uploaded 2023-12-29 | Missing upstream |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 243846 |  SHIP Activity Form |
Form and Instruction | Modified | |
| 243845 | SIRS Individual Interaction-Complex Form |
Form and Instruction | Modified | |
| 243844 | SIRS Team Member Form |
Form and Instruction | Modified | |
| 243843 | SMP Team Member Form |
Form and Instruction | Modified | |
| 243842 | SMP Individual Interaction-Basic |
Form and Instruction | Modified | |
| 243841 | SMP Group Outreach & Education |
Form and Instruction | Modified | |
| 243840 | SMP Media Outreach & Education |
Form and Instruction | Modified | |
| 232707 | SHIP/MIPPA Group Outreach Education Form |
Form and Instruction | Modified | |
| 193279 | SHIP/MIPPA Team Member Form |
Form and Instruction | Modified | |
| 193278 | SHIP/MIPPA Media Outreach Education Form |
Form and Instruction | Modified | |
| 193277 | SHIP/MIPPA Beneficiary Client Form |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/ACL |
| OMB Control No | 0985-0040 |
| Type of Information Collection | Extension without change of a currently approved collection |
| Previous ICR Reference No | 202009-0985-002 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |