Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Adult SAQ Removed 0 0 0 Form and Instruction Form #1 Attachment 18 -- HC Adult SAQ
Attachment 3 -- Female Adult - SAQ New 14692 1714 0 Form and Instruction 3 (02092018) Attachment 3 (02092018)
Attachment 4 -- Male Adult - SAQ New 13562 1582 0 Form and Instruction 4 - (02092018) Attachment 4 - (02092018)
Authorization form for the MEPS-MPC Pharmacy Survey Unchanged 44916 2246 0 Form and Instruction Form #1 Authorization form for the MEPS-MPC Pharmacy Survey
Authorization form for the MEPS-MPC Provider Survey Unchanged 78241 3912 0 Form and Instruction Form #1 Authorization Form for the MEPS-MPC - Provider
Diabetes Care SAQ Unchanged 2345 117 0 Form and Instruction Form #1 Attachment 19 -- HC Diabetes SAQ - Proxy
Form and Instruction Form #2 Attachment 20 -- HC Diabetes SAQ - Self
Home care for health care providers questionnaire Unchanged 793 119 0 Form and Instruction Form #1 Home care for health care providers questionnaire
Home care for non health care providers questionnaire Unchanged 25 5 0 Form and Instruction Form #1 Home care for non health care providers questionnaire
Hospitals questionnaire Unchanged 17820 2673 0 Form and Instruction Form #1 Hospitals questionnaire
Institutions (non-hospital) questionnaire Unchanged 238 36 0 Form and Instruction Form #1 Institutions (non-hospital) questionnaire
MEPS-HC Core Interview Unchanged 37733 57857 0 Form 1 Attachment 1 -- MEPS-HC Section Summary and Changes
MEPS-HC Validation Interview Unchanged 4781 398 0 Form and Instruction Form #1 Validation Interview Form
MPC Contact Guide/Screening Call Unchanged 35222 1174 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
Medical Organizations Survey Questionaire Unchanged 6000 1500 0 Form and Instruction 9 Attachment 100 – MPC Medical Organizations Survey Draft Questionnaire
Office based providers questionnaire Unchanged 16970 2828 0 Form and Instruction Form #1 Office based providers questionnaire
Pharmacies questionnaire Unchanged 22169 1108 0 Form and Instruction Form #1 Pharmacies questionnaire
Separately billing doctors questionnaire Unchanged 43537 9433 0 Form and Instruction Form #1 Separately billing doctors questionnaire
Total burden requested under this ICR: 339044 86702 0  
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