View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-0850	ICR Reference No: 200312-0938-005
Status: Historical Active	Previous ICR Reference No: 200108-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/12/2004
	Date Received in OIRA: 12/24/2003
Terms of Clearance: CMS will report to OMB on the progress made in examining the use states/grantees make of race, ethnicity, age, and other beneficiary demographic data collected with these forms. CMS will also continue to update OMB on progress toward coordination with AoA's NAPIS system. Lastly, CMS will submit copies of revised forms and instructions, as agreed upon 02/11/04 to OMB within 7 days for addition to the docket file.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2007	02/28/2007	02/29/2004
Responses	1,000,000	0	265
Time Burden (Hours)	116,747	0	159
Cost Burden (Dollars)	0	0	0

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