Pharmacies questionnaire

Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Document Name Document Type
Form Form #12 Pharmacies questionnaire Form and Instruction
Form #12 Pharmacies questionnaire Attachment 112 -- MPC Pharmacies Questionnaire.doc Form and Instruction
Attachment 113 -- MPC Pharmacy Contact Guide.doc Attachment 113 -- MPC Pharmacy Contact Guide IC Document
Attachment 114 -- MPC Pharmacy Cover Letter.doc Attachment 114 -- MPC Pharmacy Cover Letter IC Document
Attachment 115 -- MPC Pharmacy Instructions & Customer List - FAX Version.doc Attachment 115 -- MPC Pharmacy Instructions & Customer List - FAX Version IC Document
Attachment 116 -- MPC Pharmacy Instructions & Customer List - Phone Version.doc Attachment 116 -- MPC Pharmacy Instructions & Customer List - Phone Version IC Document
Attachment 117 -- MPC Pharmacy FAQs BROCHURE.doc Attachment 117 -- MPC Pharmacy FAQs BROCHURE IC Document
Attachment 118 -- MPC Pharmacy Fax Cover Sheet.doc Attachment 118 -- MPC Pharmacy Fax Cover Sheet IC Document
Attachment 119 -- MPC Pharmacy Fax or Mail Return Form.doc Attachment 119 -- MPC Pharmacy Fax or Mail Return Form IC Document

Information Collection (IC) Details

IC Title:	Pharmacies questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		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	Form #12	Pharmacies questionnaire	Attachment 112 -- MPC Pharmacies Questionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,760	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180,808	180,808
Annual IC Time Burden (Hours)	9,040	9,040
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 113 -- MPC Pharmacy Contact Guide	Attachment 113 -- MPC Pharmacy Contact Guide.doc	08/24/2009
Attachment 114 -- MPC Pharmacy Cover Letter	Attachment 114 -- MPC Pharmacy Cover Letter.doc	08/24/2009
Attachment 115 -- MPC Pharmacy Instructions & Customer List - FAX Version	Attachment 115 -- MPC Pharmacy Instructions & Customer List - FAX Version.doc	08/24/2009
Attachment 116 -- MPC Pharmacy Instructions & Customer List - Phone Version	Attachment 116 -- MPC Pharmacy Instructions & Customer List - Phone Version.doc	08/24/2009
Attachment 117 -- MPC Pharmacy FAQs BROCHURE	Attachment 117 -- MPC Pharmacy FAQs BROCHURE.doc	08/24/2009
Attachment 118 -- MPC Pharmacy Fax Cover Sheet	Attachment 118 -- MPC Pharmacy Fax Cover Sheet.doc	08/24/2009
Attachment 119 -- MPC Pharmacy Fax or Mail Return Form	Attachment 119 -- MPC Pharmacy Fax or Mail Return Form.doc	08/24/2009

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