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

Forms and Documents

Document Name	Status
Form Form #12 Experiences with Cancer SAQ Form and Instruction	New
Form Form #12 Pharmacies questionnaire Form and Instruction	Modified
Form Form #11 Institutions (non-hospital) questionnaire Form and Instruction	Modified
Form Form #10 Hospitals questionnaire Form and Instruction	Modified
Form Form #9 Separately billing doctors questionnaire Form and Instruction	Modified
Form Form #8 Office based providers questionnaire Form and Instruction	Modified
Form Form #7 Home care for non health care providers questionnaire Form and Instruction	Modified
Form Form #6 Home care for health care providers questionnaire Form and Instruction	Modified
Form Form #4 Permission Forms for the MEPS-MPC Form and Instruction	Modified
Form Form #2 Diabetes Care SAQ Form and Instruction	Modified
Form Form #1 Adult SAQ Form and Instruction	Modified
FW 2010 NHIS Cancer Supplement and related MEPS Cancer Questionnaire.docx Supplementary Document	2012-02-09
At door letter-Cancer Supp.docx Supplementary Document	2012-02-09
Mailed letter -Cancer Supp.docx Supplementary Document	2012-02-09
Supporting Statement Part B -- MEPS Cancer SAQ 12-7-2011.docx Supporting Statement B	2012-01-06
Attachment 108 -- MPC Hospital Instructions & Patient Records Check List - Phone Version.doc Supplementary Document	2009-08-24
Attachment 107 -- MPC Hospital Instructions & Patient Records Check List - Fax Version.doc Supplementary Document	2009-08-24
Attachment 106 -- MPC Hospital Instructions & Patient Accounts Check List - Phone Version.doc Supplementary Document	2009-08-24
Attachment 105 -- MPC Hospital Instructions & Patient Accounts Check List - FAX Version.doc Supplementary Document	2009-08-24
Attachment 104 -- MPC Hospital Fax or Mail Return Form.doc Supplementary Document	2009-08-24
Attachment 103 -- MPC Hospital Fax Cover Sheet.doc Supplementary Document	2009-08-24
Attachment 102 -- MPC Hospital FAQs BROCHURE.DOC Supplementary Document	2009-08-24
Attachment 101 -- MPC Hospital Cover Letter.doc Supplementary Document	2009-08-24
Attachment 108 -- MPC Hospital Instructions & Patient Records Check List - Phone Version.doc Supplementary Document	2009-08-24
Attachment 107 -- MPC Hospital Instructions & Patient Records Check List - Fax Version.doc Supplementary Document	2009-08-24
Attachment 106 -- MPC Hospital Instructions & Patient Accounts Check List - Phone Version.doc Supplementary Document	2009-08-24
Attachment 105 -- MPC Hospital Instructions & Patient Accounts Check List - FAX Version.doc Supplementary Document	2009-08-24
Attachment 104 -- MPC Hospital Fax or Mail Return Form.doc Supplementary Document	2009-08-24
Attachment 103 -- MPC Hospital Fax Cover Sheet.doc Supplementary Document	2009-08-24
Attachment 102 -- MPC Hospital FAQs BROCHURE.DOC Supplementary Document	2009-08-24
Attachment 101 -- MPC Hospital Cover Letter.doc Supplementary Document	2009-08-24
Attachment 100 -- MPC Hospital Contact Guide.doc Supplementary Document	2009-08-24
Attachment 98 -- MPC SBD Instructions & Patient List - Phone Version.doc Supplementary Document	2009-08-24
Attachment 97 -- MPC SBD Fax or Mail Return Form.doc Supplementary Document	2009-08-24
Attachment 96 -- MPC SBD Fax Cover Sheet.doc Supplementary Document	2009-08-24
Attachment 95 -- MPC SBD FAQs Brochure.doc Supplementary Document	2009-08-24
Attachment 94 -- MPC SBD Cover Letter.doc Supplementary Document	2009-08-24
Attachment 93 -- MPC SBD Contact Guide.doc Supplementary Document	2009-08-24
Attachment 91 -- MPC Office Based Contact Guide.doc Supplementary Document	2009-08-24
Attachment 90 -- MPC Office Based Instructions & Patient List - Phone Version.doc Supplementary Document	2009-08-24
Attachment 89 -- MPC Office Based Instructions & Patient List - FAX Version.doc Supplementary Document	2009-08-24
Attachment 88 -- MPC Office Based Fax or Mail Return Form.doc Supplementary Document	2009-08-24
Attachment 87 -- MPC Office Based Fax Cover Sheet.doc Supplementary Document	2009-08-24
Attachment 86 -- MPC Office Based FAQs Brochure.doc Supplementary Document	2009-08-24
Attachment 85 -- MPC Office Based Cover Letter.doc Supplementary Document	2009-08-24
Attachment 82 -- MPC Home Health Instructions & Client Check List - FAX Version.doc Supplementary Document	2009-08-24
Attachment 83 -- MPC Home Health Instructions & Client Check List - Phone Version.doc Supplementary Document	2009-08-24
Attachment 80 -- MPC Home Health Fax Cover Sheet.doc Supplementary Document	2009-08-24
Attachment 79 -- MPC Home Health FAQs BROCHURE.doc Supplementary Document	2009-08-24
Attachment 78 -- MPC Home Health Cover Letter.doc Supplementary Document	2009-08-24
Attachment 81 -- MPC Home Health Fax or Mail Return Form.doc Supplementary Document	2009-08-24
Attachment 83 -- MPC Home Health Instructions & Client Check List - Phone Version.doc Supplementary Document	2009-08-24
Attachment 82 -- MPC Home Health Instructions & Client Check List - FAX Version.doc Supplementary Document	2009-08-24
Attachment 81 -- MPC Home Health Fax or Mail Return Form.doc Supplementary Document	2009-08-24
Attachment 80 -- MPC Home Health Fax Cover Sheet.doc Supplementary Document	2009-08-24
Attachment 78 -- MPC Home Health Cover Letter.doc Supplementary Document	2009-08-24
Attachment 77 -- MPC Home Health Contact Guide for Organizations.doc Supplementary Document	2009-08-24
Attachment 79 -- MPC Home Health FAQs BROCHURE.doc Supplementary Document	2009-08-24
Attachment 22 -- HC MEPS-MPC Permission Form FAQs.doc Supplementary Document	2009-08-21
Attachment 27 -- HC Users of MEPS Data Handout.doc Supplementary Document	2009-08-21
Attachment 26 -- HC Validation Letter.doc Supplementary Document	2009-08-21
Attachment 25 -- HC Thank You Note.pdf Supplementary Document	2009-08-21
Attachment 24 -- HC Sorry I Missed You Note.pdf Supplementary Document	2009-08-21
Attachment 23 -- HC Showcards.doc Supplementary Document	2009-08-21
Attachment 21 -- HC MEPS Record Keeper.pdf Supplementary Document	2009-08-21
Attachment 20 -- HC MEPS Monthly Planner.pdf Supplementary Document	2009-08-21
Attachment 19 -- HC MEPS FAQs Brochure.doc Supplementary Document	2009-08-21
Attachment 18 -- HC Rds 2 & 4 Advance Letter.doc Supplementary Document	2009-08-21
Attachment 17 -- HC Rd 5 Advance Letter 2.doc Supplementary Document	2009-08-21
Attachment 16 -- HC Rd 5 Advance Letter 1.doc Supplementary Document	2009-08-21
Attachment 15 -- HC Rd 3 Advance Letter 2.doc Supplementary Document	2009-08-21
Attachment 14 -- HC Rd 3 Advance Letter 1.doc Supplementary Document	2009-08-21
Attachment 13 -- HC Rd 1 Respondent Materials Cover Letter.doc Supplementary Document	2009-08-21
Attachment 12 -- HC Rd 1 Prenotification Letter.doc Supplementary Document	2009-08-21
Attachment 11 -- HC MEPS Data Example & FAQs.doc Supplementary Document	2009-08-21
Attachment 10 -- HC MEPS Change of Address Card.pdf Supplementary Document	2009-08-21
Attachment 9 -- HC Important Information About Your Participation in MEPS.doc Supplementary Document	2009-08-21
Attachment 8 -- HC Respondent Recruitment DVD.doc Supplementary Document	2009-08-21
Attachment 7 -- HC DVD Companion Booklet.doc Supplementary Document	2009-08-21
Attachment 6 -- HC Data protection is word ONE with MEPS.doc Supplementary Document	2009-08-21
Attachment 5 -- HC Community Authority Letter.doc Supplementary Document	2009-08-21
Attachment 4 -- HC Appointment Reminder Postcard.pdf Supplementary Document	2009-08-21
Attachment 3 -- HC About MEPS-MPC Permission Form.doc Supplementary Document	2009-08-21
Attachment 2 -- HC About MEPS Booklet.pdf Supplementary Document	2009-08-21
Supporting Statement Part A -- MEPS Cancer SAQ 12-2-2011.docx Supporting Statement A	2012-01-06

IC Document Collections

IC ID	Document Title	Status
37877	MEPS-HC Core Interview Other-CAPI Specs	Modified
200754	Experiences with Cancer SAQ Form and Instruction	New
191107	Pharmacies questionnaire Form and Instruction	Modified
191106	Institutions (non-hospital) questionnaire Form and Instruction	Modified
191105	Hospitals questionnaire Form and Instruction	Modified
191104	Separately billing doctors questionnaire Form and Instruction	Modified
191103	Office based providers questionnaire Form and Instruction	Modified
191102	Home care for non health care providers questionnaire Form and Instruction	Modified
191101	Home care for health care providers questionnaire Form and Instruction	Modified
191100	Permission Forms for the MEPS-MPC Form and Instruction	Modified
191099	Diabetes Care SAQ Form and Instruction	Modified
191098	Adult SAQ Form and Instruction	Modified

ICR Details

OMB Control No: 0935-0118	ICR Reference No: 201201-0935-001
Status: Historical Active	Previous ICR Reference No: 200910-0935-001
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/17/2012
	Date Received in OIRA: 01/12/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2015	01/31/2013	01/31/2013
Responses	463,686	0	461,505
Time Burden (Hours)	83,858	0	82,767
Cost Burden (Dollars)	0	0	0

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Abstract: The MEPS includes the collection of data from household and medic medical providers to provide nationally representative unbiased estimates of health care use and expenditures for the U.S. civilian noninstitutionalized population.

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Authorizing Statute(s): US Code: 9 USC 580 Name of Law: Agency for Healthcare Research and Quality
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 67734	11/02/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 81944	12/29/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 12

IC Title	Form No.	Form Name
Office based providers questionnaire	Form #8	Office based providers questionnaire
Separately billing doctors questionnaire	Form #9	Separately billing doctors questionnaire
Hospitals questionnaire	Form #10	Hospitals questionnaire
Institutions (non-hospital) questionnaire	Form #11	Institutions (non-hospital) questionnaire
Pharmacies questionnaire	Form #12	Pharmacies questionnaire
Experiences with Cancer SAQ	Form #12	Experiences with Cancer SAQ
MEPS-HC Core Interview
Adult SAQ	Form #1	Adult SAQ
Diabetes Care SAQ	Form #2, Form #3	Diabetes care SAQ -- Self ,   Diabetes care SAQ -- Proxy
Permission Forms for the MEPS-MPC	Form #4, Form #5	Pharmacy Form ,   Provider Form
Home care for health care providers questionnaire	Form #6	Home care for health care providers questionnaire
Home care for non health care providers questionnaire	Form #7	Home care for non health care providers questionnaire

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	463,686	461,505	0	2,181	0	0
Annual Time Burden (Hours)	83,858	82,767	0	1,091	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The addition of the Experiences with Cancer SAQ to the MEPS will increase the total burden by 1,091 hours. This is a one-time increase for 2012 only.

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Annual Cost to Federal Government: $47,600,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/12/2012

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