View Information Collection Request (ICR) Package
Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
This script is used to control the display of information in this page.
Display additional information by clicking on the following:
All
Brief and OIRA conclusion
Abstract/Justification
Legal Statutes
Rulemaking
FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
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:
0985-0057
ICR Reference No:
201702-0985-002
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
HHS/ACL
Agency Tracking No:
Title:
National Beneficiary Survey of State Health Insurance Assistance Program (SHIP)
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
08/28/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
02/23/2017
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
08/31/2020
36 Months From Approved
Responses
1,350
0
0
Time Burden (Hours)
180
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
Abstract (2000 characters maximum) The National Beneficiary Surveys will gauge individuals’ satisfaction with the services they receive from the State Health Insurance Assistance (SHIP) and Senior Medicare Patrol (SMP) Programs. The survey will be the first of its kind to ascertain the quality and effectiveness of the services provided by the SHIP and SMP and to determine if beneficiaries are receiving accurate, relevant and timely information. The survey will be conducted over a three-year period beginning in Fiscal Year (FY) 2017, with multiple sites in each of the 50 states and the territories of Guam, Puerto Rico and the Virgin Islands being surveyed once. The SHIP program satisfaction survey will be conducted on a sample of beneficiaries who received assistance/counseling during two points in the year (one week in the spring and one week during the Annual Medicare Open Enrollment Period). The SMP program satisfaction survey will focus on education session presentations to determine if the target audience is satisfied with the information they are receiving. The results from these surveys will be used to measure satisfaction among individuals who receive assistance/counseling or among individuals who attend SMP education sessions, as well, as how the program can be improved to provide better service to its target population.
Authorizing Statute(s):
US Code:
42 USC 241
Name of Law: Public Health Service Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
81 FR 41974
06/28/2016
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 78601
11/08/2016
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
National Beneficiary Survey State Health Insurance Assistance Program (SHIP)
1
SHIP Phone Counseling Survey
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
1,350
0
0
1,350
0
0
Annual Time Burden (Hours)
180
0
0
180
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
This is a new data collection for the SHIP program.
Annual Cost to Federal Government:
$214,952
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Mark Snyderman 202 795-7439
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
02/23/2017
An official website of the United States government
The .gov means it's official.
The site is secure.
