View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	MEPS Alternative Sampling Design Pilot Test	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Pilot Screener	Attachment A.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,393	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	3,393	0	3,393	0	0	0
Annual IC Time Burden (Hours)	567	0	567	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Cover Letter	Cover Letter.docx	04/11/2022
Attachment B – Pilot Mailing Materials	Attachment B.docx	04/11/2022
Supporting Statement Part A	SS A clean.docx	05/24/2022
Supporting Statement Part B	SS B Clean.docx	05/24/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.