Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Adult SAQ Modified 7800 910 0 Form and Instruction 48 Adult SAQ
Authorization Form for the MEPS-MPC Provider and Pharmacy Survey Modified 38407 1920 0 Form and Instruction 52 Permission Form for Medical Providers
Form and Instruction 53 Permission Form for Pharmacies
Burdens and Economic Impacts of Medical Care SAQ New 8085 1348 0 Form and Instruction 63 Burdens and Economic Impacts of Medical Care SAQ
Cancer SAQ Removed 0 0 0 Form and Instruction 2a Cancer SAQ
Diabetes Care SAQ Modified 1398 70 0 Form and Instruction 50 Diabetes Care SAQ
Home Care Providers Event Form Modified 2700 135 0 Form and Instruction 56 Home Healthcare for Healthcare Providers
Form and Instruction 57 Home Healthcare for Non-healthcare Providers
Hospitals Event Form Modified 23217 1161 0 Form and Instruction 60 Hospital Event Form
Institutions (non-hospital) Event Form Modified 112 6 0 Form and Instruction 61 Institutions (non-hospital) Event Form
MEPS-HC Core Interview Modified 31708 46505 0 Form and Instruction 1 Access to Care
Form and Instruction 2 Additional Health Questions
Form and Instruction 3 Assets
Form and Instruction 4 Calendar Section
Form and Instruction 5 Closing Section
Form and Instruction 6 Contacting Module Section
Form and Instruction 7 Charge Payment Section
Form and Instruction 8 Child Preventive Health Section
Form and Instruction 9 Dental Visit Section
Form and Instruction 10 Event Driver Section
Form and Instruction 11 Event Enumeration Section
Form and Instruction 12 Event Follow-Up Section
Form and Instruction 13 Employment Section
Form and Instruction 14 Employment Driver Section
Form and Instruction 15 Emergency Room Section
Form and Instruction 16 Event Roster Section
Form and Instruction 17 Employment Wages Section
Form and Instruction 18 Flat Fee Section
Form and Instruction 19 Food Security Section
Form and Instruction 20 Global Section
Form and Instruction 21 Health Status Section
Form and Instruction 22 Home Health Section
Form and Instruction 23 Health Insurance Detail Section
Form and Instruction 24 Time Period Covered Detail Section
Form and Instruction 25 Hospital Stay Section
Form and Instruction 26 Health Insurance Section
Form and Instruction 27 Institutional Care Stay Section
Form and Instruction 28 Income Section
Form and Instruction 29 Institutional Care Section
Form and Instruction 30 Medical Visit Section
Form and Instruction 31 Old Employment-Private Related Insurance Section
Form and Instruction 32 Off Path Navigation Section
Form and Instruction 33 Other Medical Expenses Section
Form and Instruction 34 Outpatient Department Section
Form and Instruction 35 Priority Condition Section
Form and Instruction 36 Prescribed Medicines Section
Form and Instruction 37 Provider Probes Section
Form and Instruction 38 Old Public Related Insurance Section
Form and Instruction 39 Provider Roster Section
Form and Instruction 40 Quality Supplement Section
Form and Instruction 41 Reenumeration A Section
Form and Instruction 42 Reenumeration B Section
Form and Instruction 43 Respondent Forms Section
Form and Instruction 44 Review of Employment Section
Form and Instruction 45 Start-Restart Section
Form and Instruction 46 Telehealth Section
MEPS-HC Validation Interview Modified 1826 152 0 Form and Instruction 54a Validation Letter
Form and Instruction 54b Phone Validation Form
MPC Contact Guide/Screening Call Modified 38683 3224 0 Form and Instruction 55 MPC Contact Guide & Screening Call
Office Based Providers Form Modified 26040 1302 0 Form and Instruction 58 Office Based Provider Event Form
Pharmacies Event Form Modified 191306 9565 0 Form and Instruction 62 Pharmacies Event Form
Preventive Care SAQ Modified 7800 910 0 Form and Instruction 49 PSAQ
Separately Billing Doctors Form Modified 5611 281 0 Form and Instruction 59 Separately Billing Doctors Event Form
Total burden requested under this ICR: 384693 67489 0  
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