Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Adult SAQ New 21000 2450 0 Form and Instruction Form #1
Diabetes Care SAQ New 1800 90 0 Form and Instruction Form #2
Form and Instruction Form #3
Home care for health care providers questionnaire New 2867 239 0 Form and Instruction Form #6
Home care for non health care providers questionnaire New 152 13 0 Form and Instruction Form #7
Hospitals questionnaire New 35113 2926 0 Form and Instruction Form #10
Institutions (non-hospital) questionnaire New 108 9 0 Form and Instruction Form #11
MEPS-HC Core Interview Modified 37500 56250 0 Other-CAPI Specs
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Office based providers questionnaire New 79257 6605 0 Form and Instruction Form #8
Permission Forms for the MEPS-MPC New 78000 3900 0 Form and Instruction Form #4
Form and Instruction Form #5
Pharmacies questionnaire New 180808 9040 0 Form and Instruction Form #12
Separately billing doctors questionnaire New 24900 1245 0 Form and Instruction Form #9
Total burden requested under this ICR: 461505 82767 0  
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