Diabetes Care SAQ

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⚠️ Notice: This information collection may be referencing outdated material.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 #2 Diabetes Care SAQ Form and Instruction
Form #2 Diabetes care SAQ -- Self Attachment 72 -- HC Diabetes SAQ - Self.doc Form and Instruction
Form #3 Diabetes care SAQ -- Proxy Attachment 71 -- HC Diabetes SAQ - Proxy.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Diabetes Care SAQ	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 #2	Diabetes care SAQ -- Self	Attachment 72 -- HC Diabetes SAQ - Self.doc		Yes	Yes	Paper Only
Form and Instruction	Form #3	Diabetes care SAQ -- Proxy	Attachment 71 -- HC Diabetes SAQ - Proxy.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,800	1,800
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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