Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Adult SAQ Modified 28254 3296 0 Form and Instruction Form #1 Attachment 21 -- HC Adult SAQ
Authorization form for the MEPS-MPC Pharmacy Survey New 44916 2246 0 Form and Instruction Form #1 Authorization form for the MEPS-MPC Pharmacy Survey
Authorization form for the MEPS-MPC Provider Survey New 75343 3767 0 Form and Instruction Form #1 Authorization Form for the MEPS-MPC - Provider
Diabetes Care SAQ Modified 2345 117 0 Form and Instruction Form #1 Attachment 22 -- HC Diabetes SAQ - Proxy
Form and Instruction Form #2 Attachment 23 -- HC Diabetes SAQ - Self
Experiences with Cancer SAQ Removed 0 0 0 Form and Instruction Form #12 Experiences with Cancer SAQ
Home care for health care providers questionnaire Modified 3023 252 0 Form and Instruction Form #1 Home care for health care providers questionnaire
Home care for non health care providers questionnaire Modified 231 19 0 Form and Instruction Form #1 Home care for non health care providers questionnaire
Hospitals questionnaire Modified 32500 2708 0 Form and Instruction Form #1 Hospitals questionnaire
Institutions (non-hospital) questionnaire Modified 150 13 0 Form and Instruction Form #1 Institutions (non-hospital) questionnaire
MEPS-HC Core Interview Modified 37733 54084 0 Form Form #1 Attachment 1 -- MEPS-HC Section Summary and Changes
MEPS-HC Validation Interview New 4781 398 0 Form and Instruction Form #1 Validation Interview Form
MPC Contact Guide/Screening Call New 34000 1700 0 Form and Instruction Form #1 Home Health Contact Guide for Organizations
Form and Instruction Form #2 Office Based Contact Guide
Form and Instruction Form #3 SBD Contact Guide
Form and Instruction Form #4 Hospital Contact Guide
Form and Instruction Form #5 Institution Contact Guide
Form and Instruction Form #6 Pharmacy Contact Guide
Office based providers questionnaire Modified 62640 5220 0 Form and Instruction Form #1 Office based providers questionnaire
Permission Forms for the MEPS-MPC Removed 0 0 0 Form and Instruction Form #4 Pharmacy Form
Form and Instruction Form #5 Provider Form
Pharmacies questionnaire Modified 158440 7922 0 Form and Instruction Form #1 Pharmacies questionnaire
Separately billing doctors questionnaire Modified 21600 1080 0 Form and Instruction Form #1 Separately billing doctors questionnaire
Total burden requested under this ICR: 505956 82822 0  
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