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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
MEPS-HC Core Interview
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
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
Attachment 29
Attachment 29 –HC Access to Care Section
Attachment 29 HC Access to Care Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 30
Attachment 30 – HC Condition Enumeration Section
Attachment 30 HC Event Enumeration Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 31
Attachment 31 – Attachment 31 HC Assets Section.
Attachment 31 HC Assets Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 32
Attachment 32 – Attachment 32 HC Calendar Section
Attachment 32 HC Calendar Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 33
Attachment 33 Additional healthcare Section
Attachment 33 Additional healthcare Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 34
Attachment 34 HC Closing Section
Attachment 34 HC Closing Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 35
Attachment 35 HC Start_Restart
Attachment 35 HC Start_Restart Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 36
Attachment 36 HC Charge Payment Section
Attachment 36 HC Charge Payment Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 37
Attachment 37 HC Flat Fee Section
Attachment 37 HC Flat Fee Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 38
Attachment 38 – HC Child Preventive Health Supplement Section
Attachment 38 Child Preventive Health Supplement Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 39
Attachment 39 – HC Institutional Care Section
Attachment 39 HC Institutional Care Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 40
Attachment 40 – HC Dental Care Section
Attachment 40 HC Dental Care Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 41
Attachment 41 – HC Event Driver Section
Attachment 41 HC Event Driver Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 42
Attachment 42 – HC Employment (EM) Section
Attachment 42 HC Employment (EM) Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 43
Attachment 43 – HC Review of Employment Information (RJ) Section
Attachment 43 HC Review of Employment Information (RJ) Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 44
Attachment 44 – HC Employment Driver (OE) Section
Attachment 44 HC Employment Driver (OE) Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 45
Attachment 45 – HC Employment Wage (EW) Section
Attachment 45 Employment Wage (EW) Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 46
Attachment 46 – HC Emergency Room Section
Attachment 46 Emergency Room Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 47
Attachment 47 Event Roster Section
Attachment 47 Event Roster Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 48
Attachment 48 Health Status Section
Attachment 48 Health Status Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 49
Attachment 49 HC Help Text
Attachment 49 HC Help Text.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 50
Attachment 50 Home Health Section
Attachment 50 Home Health Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 51
Attachment 51 Health Insurance (HX) Section
Attachment 51 Health Insurance (HX) Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 52 HC
Attachment 52 HC Private Health Insurance Detail (HP) Section
Attachment 52 HC Private Health Insurance Detail (HP) Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 53
Attachment 53 HC Time Covered Detail (HQ) Section
Attachment 53 HC Time Covered Detail (HQ) Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 54
Attachment 54 HC Managed Care (MC) Section
Attachment 54 HC Managed Care (MC) Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 55
Attachment 55 HC Old Employment Health Insurance (OE) Section
Attachment 55 HC Old Employment Health Insurance (OE) Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 56
Attachment 56 HC Old Public Related Insurance (PR) Section
Attachment 56 HC Old Public Related Insurance (PR) Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 57
Attachment 57 HC Hospital Stay Section
Attachment 57 HC Hospital Stay Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 58
Attachment 58 HC Income Section
Attachment 58 HC Income Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 59
Attachment 59 HC Medical Provider Section
Attachment 59 HC Medical Provider Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 60
Attachment 60 HC Other Medical Expense Section
Attachment 60 HC Other Medical Expense Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 61
Attachment 61 HC Outpatient Department Section
Attachment 61 HC Outpatient Department Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 62
Attachment 62 HC Quality Supplement Section
Attachment 62 HC Quality Supplement Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 63
Attachment 63 HC Respondent Forms Section
Attachment 63 HC Respondent Forms Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 64
Attachment 64 HC Priority Conditions Enumeration Section
Attachment 64 HC Priority Conditions Enumeration Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 65
Attachment 65 HC Prescribed Medicines Section
Attachment 65 HC Prescribed Medicines Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 66
Attachment 66 HC Provider Probes Section
Attachment 66 HC Provider Probes Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 67
Attachment 67 HC Provider Roster Section
Attachment 67 HC Provider Roster Section.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 68
Attachment 68 HC Reenumeration Subsection
Attachment 68 HC Reenumeration Subsection A.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 69
Attachment 69 HC Reenumeration Subsection B
Attachment 69 HC Reenumeration Subsection B.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 70
Attachment 70 HC RU Information Screener
Attachment 70 HC RU Information Screener.docx
Yes
Yes
Fillable Fileable
Form and Instruction
Attachment 71
Attachment 71 HC Event Follow Up Section
Attachment 71 HC Event Follow Up Section.pdf
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:
13,338
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
33,345
0
0
0
0
33,345
Annual IC Time Burden (Hours)
51,129
0
0
0
0
51,129
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Attachment 2 - HC Why is Participation in MEPS so Important
02-HC Why is Participation in MEPS so Important.pdf
09/10/2015
Attachment 4 -- HC Policy Impact Award
Attachment 4 -- HC Policy Impact Award.doc
09/24/2012
Attachment 3 -- HC MEPS A Survey of Health Care Use and Spending
03-HC MEPS A Survey of Health Care Use and Spending.pdf
09/10/2015
Attachment 8 – HC Important Information About Your Participation in MEPS
08-HC Important Information About Your Participatio in MEPS.doc
09/11/2015
Attachment 9 – HC MEPS Data Example & FAQs
09-HC MEPS Data Example&FAQs.docx
09/11/2015
Attachment 10 – HC Respondent Letters, Postcards and Notes
10-HC Respondent Letters, Postcards and Notes.docx
09/11/2015
Attachment 11 – HC MEPS FAQs Brochure
11-HC MEPS FAQs Brochure.docx
09/11/2015
Attachment 12 – HC MEPS Monthly Planner
12-HC MEPS Monthly Planner.pdf
09/11/2015
Attachment 13 – HC MEPS Record Keeper
13-HC MEPS Record Keeper.pdf
09/11/2015
Attachment 14 – HC Showcards
14-HC Showcards.docx
09/11/2015
Attachment 16 – HC Certificate of Appreciation
16-HC Certificate of Appreciation.pdf
09/11/2015
Attachment 17 – HC Who Uses MEPS Data
17-HC Who Uses MEPS Data.docx
09/11/2015
Attachment 24 – HC MEPS Tip Sheet
24-MEPS Tip Sheet.docx
09/11/2015
Attachment 25 – HC Tips for Making Your MEPS Interview Easier
25-HC Tips for Making Your MEPS Interview Easier.docx
09/11/2015
Attachment 5 – HC About the MEPS-MPC Authorization Form
05-HC About the MEPS-MPC Authorization Form.docx
09/10/2015
Attachment 6 – HC Data protection is word ONE with MEPS
06-HC Data protection is word ONE with MEPS.doc
09/11/2015
Attachment 15 – HC Validation Letter
15-HC Validation Letter.doc
09/11/2015
Attachment 4 – HC What MEPS tells us about…Charts
04-HC What MEPS tells us about...Charts.docx
09/10/2015
Attachment 7 – HC Respondent Recruitment Video
Attachment 7 HC Respondent Recruitment Video Link.msg
09/11/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.