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 Attachment 20 HC Adult SAQ Female
Form and Instruction Attachment 19 Attachment 19 HC Adult SAQ Male
COVID-19 Questions Removed 0 0 0 Form and Instruction 1 PE COVID-19
Adult SAQ New 2844 332 0 Form and Instruction 1a Adult SAQ
Attachment 19 – HC Adult SAQ – Male Removed 0 0 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 Removed 0 0 0 Form and Instruction Attachment C Attachment C
Authorization form for the MEPS-MPC Pharmacy Survey Removed 0 0 0 Form and Instruction Attachment 24 Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy
Authorization form for the MEPS-MPC Provider and Pharmacy Survey Modified 54755 2738 0 Form and Instruction Attachment 25 Attachment 25 HC Authorization Form for the MEPS MPC Provider
Form and Instruction Attachment 24 Authorization Form for the MEPS MPC Pharmacy Survey
COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire Removed 0 0 0 Form and Instruction Attachment A – COVID-19 Questions Attachment A – COVID-19 Questions
Form and Instruction Attachment B Attachment B
Cancer SAQ New 1500 500 0 Form and Instruction 2a Cancer SAQ
Diabetes Care SAQ Modified 1000 50 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 Removed 0 0 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 Removed 0 0 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 Providers Event Form Modified 5139 257 0 Form and Instruction 4a Home Health Event Form for Health Care Providers
Form and Instruction 5a Home Health Event Form for Non-Health Care Providers
Home care for non health care providers questionnaire Removed 0 0 0 Form and Instruction Attachment 82 Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers
Hospitals questionnaire Modified 62265 3113 0 Form and Instruction Attachment 91 Attachment 91 – MPC Hospital Provider Questionnaire
Institutions (non-hospital) questionnaire Modified 153 8 0 Form and Instruction Attachment 96 Attachment 96 – MPC Institution Provider Questionnaire
MEPS-HC Core Interview Modified 29375 43083 0 Other-Explanatory
MEPS-HC Validation Interview Modified 4225 352 0 Form and Instruction Attachment 26 Attachment 26 HC MEPS Validation Interview
MPC Contact Guide/Screening Call Modified 54758 4563 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 Modified 64285 3214 0 Form and Instruction Attachment 83 Attachment 83 – MPC Office-Based Doctor Provider Questionnaire
Pharmacies questionnaire Modified 341370 17069 0 Form and Instruction Attachment 98 Attachment 98 – MPC Pharmacy Provider Questionnaire
Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Removed 0 0 0 Form and Instruction 108 Attachment 108 - Household Component Core Instrument Link
Preventive Care SAQ New 2844 332 0 Form and Instruction 5a Preventative Care SAQ
Separately billing doctors questionnaire Modified 17766 888 0 Form and Instruction Attachment 87 Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire
Total burden requested under this ICR: 642279 76499 0  
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