SHIP/MIPPA Team Member Form

State Health Insurance Assistance Program (SHIP) Client Contact Forms

Documents and Forms

Document Name Document Type
SHIP/MIPPA Team Member Form Form and Instruction
SIRS Team Member Form 0040 SIRS Team Member Form 2023 Ins 5.docx Form and Instruction
SIRS Team Member Form 0040 SIRS Team Member Form 2023 Ins 5.docx Form and Instruction

Information Collection (IC) Details

IC Title:	SHIP/MIPPA Team Member Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	SIRS Team Member Form	0040 SIRS Team Member Form 2023 Ins 5.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 216	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	16,200	16,200
Annual IC Time Burden (Hours)	1,008	1,008
Annual IC Cost Burden (Dollars)	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.