Information Collection List

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