State Health Insurance Assistance Program (SHIP) Client Contact Forms

ICR 202310-0985-004

OMB: 0985-0040

Federal Form Document

Forms and Documents

Document Name	Status
SHIP Activity Form Form and Instruction	Modified
SIRS Individual Interaction-Complex Form Form and Instruction	Modified
SIRS Team Member Form Form and Instruction	Modified
SMP Team Member Form Form and Instruction	Modified
SMP Individual Interaction-Basic Form and Instruction	Modified
SMP Group Outreach & Education Form and Instruction	Modified
SMP Media Outreach & Education Form and Instruction	Modified
SHIP/MIPPA Group Outreach Education Form Form and Instruction	Modified
SHIP/MIPPA Team Member Form Form and Instruction	Modified
SHIP/MIPPA Media Outreach Education Form Form and Instruction	Modified
SHIP/MIPPA Beneficiary Client Form Form and Instruction	Modified
0040 OMB SS Dec 2023 - 12.18.23 PRA KJG Edits.docx Supporting Statement A	2023-12-29

IC Document Collections

IC ID	Document Title	Status
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