Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Attachment 20 HC Adult SAQ Female Removed 0 0 0 Form and Instruction Attachment 20
Form and Instruction Attachment 19
COVID-19 Questions Removed 0 0 0 Form and Instruction 1
Adult SAQ New 2844 332 0 Form and Instruction 1a
Attachment 19 – HC Adult SAQ – Male Removed 0 0 0 Form and Instruction Attachment 19
Form and Instruction Attachment 18
Attachment C – Social and Health Experiences Self-Administered Questionnaire Removed 0 0 0 Form and Instruction Attachment C
Authorization form for the MEPS-MPC Pharmacy Survey Removed 0 0 0 Form and Instruction Attachment 24
Authorization form for the MEPS-MPC Provider and Pharmacy Survey Modified 54755 2738 0 Form and Instruction Attachment 25
Form and Instruction Attachment 24
COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire Removed 0 0 0 Form and Instruction Attachment A – COVID-19 Questions
Form and Instruction Attachment B
Cancer SAQ New 1500 500 0 Form and Instruction 2a
Diabetes Care SAQ Modified 1000 50 0 Form and Instruction Attachment 22
Form and Instruction Attachment 23
HC Adult SAQ that includes Mental Health Questions Removed 0 0 0 Form and Instruction 106a
Form and Instruction 106b
Health Insurance Cost Sharing Collection- 2020 Removed 0 0 0 Form and Instruction 107a
Form and Instruction 107b
Form and Instruction 107c
Form and Instruction 107d
Home Care Providers Event Form Modified 5139 257 0 Form and Instruction 4a
Form and Instruction 5a
Home care for non health care providers questionnaire Removed 0 0 0 Form and Instruction Attachment 82
Hospitals questionnaire Modified 62265 3113 0 Form and Instruction Attachment 91
Institutions (non-hospital) questionnaire Modified 153 8 0 Form and Instruction Attachment 96
MEPS-HC Core Interview Modified 29375 43083 0 Other-Explanatory
MEPS-HC Validation Interview Modified 4225 352 0 Form and Instruction Attachment 26
MPC Contact Guide/Screening Call Modified 54758 4563 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
Office based providers questionnaire Modified 64285 3214 0 Form and Instruction Attachment 83
Pharmacies questionnaire Modified 341370 17069 0 Form and Instruction Attachment 98
Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Removed 0 0 0 Form and Instruction 108
Preventive Care SAQ New 2844 332 0 Form and Instruction 5a
Separately billing doctors questionnaire Modified 17766 888 0 Form and Instruction Attachment 87
Total burden requested under this ICR: 642279 76499 0  
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