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 Adult SAQ
Diabetes Care SAQ New 1800 90 0 Form and Instruction Form #2 Diabetes care SAQ -- Self
Form and Instruction Form #3 Diabetes care SAQ -- Proxy
Home care for health care providers questionnaire New 2867 239 0 Form and Instruction Form #6 Home care for health care providers questionnaire
Home care for non health care providers questionnaire New 152 13 0 Form and Instruction Form #7 Home care for non health care providers questionnaire
Hospitals questionnaire New 35113 2926 0 Form and Instruction Form #10 Hospitals questionnaire
Institutions (non-hospital) questionnaire New 108 9 0 Form and Instruction Form #11 Institutions (non-hospital) questionnaire
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 Office based providers questionnaire
Permission Forms for the MEPS-MPC New 78000 3900 0 Form and Instruction Form #4 Pharmacy Form
Form and Instruction Form #5 Provider Form
Pharmacies questionnaire New 180808 9040 0 Form and Instruction Form #12 Pharmacies questionnaire
Separately billing doctors questionnaire New 24900 1245 0 Form and Instruction Form #9 Separately billing doctors questionnaire
Total burden requested under this ICR: 461505 82767 0  
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