Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Attachment 20 HC Adult SAQ Female Modified 12984 1515 0 Form and Instruction Attachment 20
Form and Instruction Attachment 19
3. Veteran SAQ New 1350 338 0 Form and Instruction Attachment 21
Attachment 19 – HC Adult SAQ – Male Modified 11985 1398 0 Form and Instruction Attachment 19
Form and Instruction Attachment 18
Authorization form for the MEPS-MPC Pharmacy Survey Modified 39692 1985 0 Form and Instruction Attachment 24
Authorization form for the MEPS-MPC Provider Survey Modified 69142 3457 0 Form and Instruction Attachment 25
Diabetes Care SAQ Modified 2072 104 0 Form and Instruction Attachment 22
Form and Instruction Attachment 23
Home care for health care providers questionnaire Modified 972 146 0 Form and Instruction Attachment 78
Home care for non health care providers questionnaire Modified 11 2 0 Form and Instruction Attachment 82
Hospitals questionnaire Modified 17311 2597 0 Form and Instruction Attachment 91
Institutions (non-hospital) questionnaire Modified 238 36 0 Form and Instruction Attachment 96
MEPS-HC Core Interview Modified 33345 51129 0 Form and Instruction Attachment 29
Form and Instruction Attachment 30
Form and Instruction Attachment 31
Form and Instruction Attachment 32
Form and Instruction Attachment 33
Form and Instruction Attachment 34
Form and Instruction Attachment 35
Form and Instruction Attachment 36
Form and Instruction Attachment 37
Form and Instruction Attachment 38
Form and Instruction Attachment 39
Form and Instruction Attachment 40
Form and Instruction Attachment 41
Form and Instruction Attachment 42
Form and Instruction Attachment 43
Form and Instruction Attachment 44
Form and Instruction Attachment 45
Form and Instruction Attachment 46
Form and Instruction Attachment 47
Form and Instruction Attachment 48
Form and Instruction Attachment 49
Form and Instruction Attachment 50
Form and Instruction Attachment 51
Form and Instruction Attachment 52 HC
Form and Instruction Attachment 53
Form and Instruction Attachment 54
Form and Instruction Attachment 55
Form and Instruction Attachment 56
Form and Instruction Attachment 57
Form and Instruction Attachment 58
Form and Instruction Attachment 59
Form and Instruction Attachment 60
Form and Instruction Attachment 61
Form and Instruction Attachment 62
Form and Instruction Attachment 63
Form and Instruction Attachment 64
Form and Instruction Attachment 65
Form and Instruction Attachment 66
Form and Instruction Attachment 67
Form and Instruction Attachment 68
Form and Instruction Attachment 69
Form and Instruction Attachment 70
Form and Instruction Attachment 71
MEPS-HC Validation Interview Modified 4225 352 0 Form and Instruction Attachment 26
MPC Contact Guide/Screening Call Modified 36598 1220 0 Form and Instruction Attachment 72
Form and Instruction Attachment 73
Form and Instruction Attachment 74
Form and Instruction Attachment 75
Form and Instruction Attachment 76
Form and Instruction Attachment 77
Medical Organizations Survey Questionaire Removed 0 0 0 Form and Instruction 9
Office based providers questionnaire Modified 18497 3083 0 Form and Instruction Attachment 83
Pharmacies questionnaire Modified 20203 1010 0 Form and Instruction Attachment 98
Separately billing doctors questionnaire Modified 42894 9294 0 Form and Instruction Attachment 87
Total burden requested under this ICR: 311519 77666 0  
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