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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Attachment 20 HC Adult SAQ Female
Unchanged
12984
1515
0
Form and Instruction
Attachment 20
Attachment 20 HC Adult SAQ Female
Form and Instruction
Attachment 19
Attachment 19 HC Adult SAQ Male
Attachment 19 – HC Adult SAQ – Male
Unchanged
11985
1398
0
Form and Instruction
Attachment 19
Attachment 19 – HC Adult SAQ – Male
Form and Instruction
Attachment 18
Attachment 18 HC Adult SAQ
Attachment C – Social and Health Experiences Self-Administered Questionnaire
New
27059
3157
0
Form and Instruction
Attachment C
Attachment C
Authorization form for the MEPS-MPC Pharmacy Survey
Unchanged
39692
1985
0
Form and Instruction
Attachment 24
Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy
Authorization form for the MEPS-MPC Provider Survey
Unchanged
69142
3457
0
Form and Instruction
Attachment 25
Attachment 25 HC Authorization Form for the MEPS MPC Provider
COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire
New
13338
222
0
Form and Instruction
Attachment A – COVID-19 Questions
Attachment A – COVID-19 Questions
Form and Instruction
Attachment B
Attachment B
Diabetes Care SAQ
Unchanged
2072
104
0
Form and Instruction
Attachment 22
Attachment 22 -- HC Diabetes SAQ - Proxy
Form and Instruction
Attachment 23
Attachment 23 -- HC Diabetes SAQ - Self
HC Adult SAQ that includes Mental Health Questions
Unchanged
20476
1194
0
Form and Instruction
106a
Attachment 106a.REV_Female PSAQ with Mental Health Content
Form and Instruction
106b
Attachment106b.REV_Male PSAQ with Mental Health Content
Health Insurance Cost Sharing Collection- 2020
Unchanged
8135
6101
0
Form and Instruction
107a
Attachment 107a.Protocol A (Medicare)
Form and Instruction
107b
Attachment 107b.Protocol B (Employer)
Form and Instruction
107c
Attachment 107c.Protocol C (Private with Medicare)_
Form and Instruction
107d
Attachment 107d.Protocol D (Other)
Home care for health care providers questionnaire
Unchanged
972
146
0
Form and Instruction
Attachment 78
Attachment 78 – MPC Home Care Provider Questionnaire for Health Care Providers
Home care for non health care providers questionnaire
Unchanged
11
2
0
Form and Instruction
Attachment 82
Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers
Hospitals questionnaire
Unchanged
17311
2597
0
Form and Instruction
Attachment 91
Attachment 91 – MPC Hospital Provider Questionnaire
Institutions (non-hospital) questionnaire
Unchanged
238
36
0
Form and Instruction
Attachment 96
Attachment 96 – MPC Institution Provider Questionnaire
MEPS-HC Core Interview
Unchanged
33345
51129
0
Form and Instruction
Attachment 29
Attachment 29 –HC Access to Care Section
Form and Instruction
Attachment 30
Attachment 30 – HC Condition Enumeration Section
Form and Instruction
Attachment 31
Attachment 31 – Attachment 31 HC Assets Section.
Form and Instruction
Attachment 32
Attachment 32 – Attachment 32 HC Calendar Section
Form and Instruction
Attachment 33
Attachment 33 Additional healthcare Section
Form and Instruction
Attachment 34
Attachment 34 HC Closing Section
Form and Instruction
Attachment 35
Attachment 35 HC Start_Restart
Form and Instruction
Attachment 36
Attachment 36 HC Charge Payment Section
Form and Instruction
Attachment 37
Attachment 37 HC Flat Fee Section
Form and Instruction
Attachment 38
Attachment 38 – HC Child Preventive Health Supplement Section
Form and Instruction
Attachment 39
Attachment 39 – HC Institutional Care Section
Form and Instruction
Attachment 40
Attachment 40 – HC Dental Care Section
Form and Instruction
Attachment 41
Attachment 41 – HC Event Driver Section
Form and Instruction
Attachment 42
Attachment 42 – HC Employment (EM) Section
Form and Instruction
Attachment 43
Attachment 43 – HC Review of Employment Information (RJ) Section
Form and Instruction
Attachment 44
Attachment 44 – HC Employment Driver (OE) Section
Form and Instruction
Attachment 45
Attachment 45 – HC Employment Wage (EW) Section
Form and Instruction
Attachment 46
Attachment 46 – HC Emergency Room Section
Form and Instruction
Attachment 47
Attachment 47 Event Roster Section
Form and Instruction
Attachment 48
Attachment 48 Health Status Section
Form and Instruction
Attachment 49
Attachment 49 HC Help Text
Form and Instruction
Attachment 50
Attachment 50 Home Health Section
Form and Instruction
Attachment 51
Attachment 51 Health Insurance (HX) Section
Form and Instruction
Attachment 52 HC
Attachment 52 HC Private Health Insurance Detail (HP) Section
Form and Instruction
Attachment 53
Attachment 53 HC Time Covered Detail (HQ) Section
Form and Instruction
Attachment 54
Attachment 54 HC Managed Care (MC) Section
Form and Instruction
Attachment 55
Attachment 55 HC Old Employment Health Insurance (OE) Section
Form and Instruction
Attachment 56
Attachment 56 HC Old Public Related Insurance (PR) Section
Form and Instruction
Attachment 57
Attachment 57 HC Hospital Stay Section
Form and Instruction
Attachment 58
Attachment 58 HC Income Section
Form and Instruction
Attachment 59
Attachment 59 HC Medical Provider Section
Form and Instruction
Attachment 60
Attachment 60 HC Other Medical Expense Section
Form and Instruction
Attachment 61
Attachment 61 HC Outpatient Department Section
Form and Instruction
Attachment 62
Attachment 62 HC Quality Supplement Section
Form and Instruction
Attachment 63
Attachment 63 HC Respondent Forms Section
Form and Instruction
Attachment 64
Attachment 64 HC Priority Conditions Enumeration Section
Form and Instruction
Attachment 65
Attachment 65 HC Prescribed Medicines Section
Form and Instruction
Attachment 66
Attachment 66 HC Provider Probes Section
Form and Instruction
Attachment 67
Attachment 67 HC Provider Roster Section
Form and Instruction
Attachment 68
Attachment 68 HC Reenumeration Subsection
Form and Instruction
Attachment 69
Attachment 69 HC Reenumeration Subsection B
Form and Instruction
Attachment 70
Attachment 70 HC RU Information Screener
Form and Instruction
Attachment 71
Attachment 71 HC Event Follow Up Section
MEPS-HC Validation Interview
Unchanged
4225
352
0
Form and Instruction
Attachment 26
Attachment 26 HC MEPS Validation Interview
MPC Contact Guide/Screening Call
Unchanged
36598
1220
0
Form and Instruction
Attachment 72
Attachment 72 – MPC Hospital Contact Guide
Form and Instruction
Attachment 73
Attachment 73 – MPC Office-Based Doctor Contact Guide
Form and Instruction
Attachment 74
Attachment 74 – MPC Home Care Contact
Form and Instruction
Attachment 75
Attachment 75 – MPC Institution Contact Guide
Form and Instruction
Attachment 76
Attachment 76 – MPC Pharmacy Contact Guide
Form and Instruction
Attachment 77
Attachment 77 – MPC Separate Billing Doctor Contact Guide
Office based providers questionnaire
Unchanged
18497
3083
0
Form and Instruction
Attachment 83
Attachment 83 – MPC Office-Based Doctor Provider Questionnaire
Pharmacies questionnaire
Unchanged
20203
1010
0
Form and Instruction
Attachment 98
Attachment 98 – MPC Pharmacy Provider Questionnaire
Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core
Unchanged
200
307
0
Form and Instruction
108
Attachment 108 - Household Component Core Instrument Link
Separately billing doctors questionnaire
Unchanged
42894
9294
0
Form and Instruction
Attachment 87
Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire
Total burden requested under this ICR:
379377
88309
0
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