Information Collection

MEPS-HC Core Interview

IC 37877 under ICR 201201-0935-001 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 28 -- HC Access to Care Section.doc	Other-CAPI Specs
Attachment 29 -- HC Accident, Injury & Conditions Section.doc	Other-CAPI Specs
Attachment 30 -- HC Assets Section.doc	Other-CAPI Specs
Attachment 31 -- HC Calendar Section.doc	Other-CAPI Specs
Attachment 32 -- HC Charge Payment Section.doc	Other-CAPI Specs
Attachment 33 -- HC Child Preventive Health Supplement Section.doc	Other-CAPI Specs
Attachment 34 -- HC Condition Enumeration Section.doc	Other-CAPI Specs
Attachment 35 -- HC Dental Care Section.doc	Other-CAPI Specs
Attachment 36 -- HC Disability Days Section.doc	Other-CAPI Specs
Attachment 37 -- HC Emergency Room Section.doc	Other-CAPI Specs
Attachment 38 -- HC Employment Driver Section.doc	Other-CAPI Specs
Attachment 39 -- HC Employment Section.doc	Other-CAPI Specs
Attachment 40 -- HC Employment Wage Section.doc	Other-CAPI Specs
Attachment 41 -- HC Event Roster Section.doc	Other-CAPI Specs
Attachment 42 -- HC Flat Fee Section.doc	Other-CAPI Specs
Attachment 43 -- HC Health Insurance Section.doc	Other-CAPI Specs
Attachment 46 -- HC Hospital Stay Section.doc	Other-CAPI Specs
Attachment 44 -- HC Health Status Section.doc	Other-CAPI Specs
Attachment 45 -- HC Home Health Section.doc	Other-CAPI Specs
Attachment 47 -- HC Income Section.doc	Other-CAPI Specs
Attachment 48 -- HC Managed Care Section.doc	Other-CAPI Specs
Attachment 49 -- HC Medical Provider Visits Section.doc	Other-CAPI Specs
Attachment 50 -- HC Old Employment & Private Related Insurance Section.doc	Other-CAPI Specs
Attachment 51 -- HC Old Public Related Insurance Section.doc	Other-CAPI Specs
Attachment 52 -- HC Other Medical Expenses Section.doc	Other-CAPI Specs
Attachment 53 -- HC Outpatient Department Section.doc	Other-CAPI Specs
Attachment 54 -- HC Prescribed Medicines Section.doc	Other-CAPI Specs
Attachment 55 -- HC Preventive Care Section.doc	Other-CAPI Specs
Attachment 56 -- HC Priority Conditions Enumeration Section.doc	Other-CAPI Specs
Attachment 57 -- HC Private Health Insurance Detail Section.doc	Other-CAPI Specs
Attachment 58 -- HC Provider Directory Section.doc	Other-CAPI Specs
Attachment 59 -- HC Provider Probes Section.doc	Other-CAPI Specs
Attachment 60 -- HC Provider Roster Section.doc	Other-CAPI Specs
Attachment 61 -- HC Quality (Priority Conditions) Supplement Section.doc	Other-CAPI Specs
Attachment 62 -- HC Reenumeration Subsection A.doc	Other-CAPI Specs
Attachment 63 -- HC Reenumeration Subsection B.doc	Other-CAPI Specs
Attachment 64 -- HC Review of Employment Information Section.doc	Other-CAPI Specs
Attachment 65 -- HC Satisfaction with Health Plan Section.doc	Other-CAPI Specs
Attachment 66 -- HC Time Period Covered Detail Section.doc	Other-CAPI Specs
Attachment 67 -- HC Information Screen Section.doc	Other-CAPI Specs
Attachment 68 -- HC F1 Help Text.doc	Other-CAPI Specs
Attachment 69 -- HC Closing Section.doc	Other-CAPI Specs
Attachment 2 -- HC About MEPS Booklet.pdf Attachment 2 -- HC About MEPS Booklet	IC Document
Attachment 3 -- HC About MEPS-MPC Permission Form.doc Attachment 3 -- HC About MEPS-MPC Permission Form	IC Document
Attachment 4 -- HC Appointment Reminder Postcard.pdf Attachment 4 -- HC Appointment Reminder Postcard	IC Document
Attachment 5 -- HC Community Authority Letter.doc Attachment 5 -- HC Community Authority Letter	IC Document
Attachment 6 -- HC Data protection is word ONE with MEPS.doc Attachment 6 -- HC Data protection is word ONE with MEPS	IC Document
Attachment 7 -- HC DVD Companion Booklet.doc Attachment 7 -- HC DVD Companion Booklet	IC Document
Attachment 8 -- HC Respondent Recruitment DVD.doc Attachment 8 -- HC Respondent Recruitment DVD	IC Document
Attachment 9 -- HC Important Information About Your Participation in MEPS.doc Attachment 9 -- HC Important Information About Your Participation in MEPS	IC Document
Attachment 10 -- HC MEPS Change of Address Card.pdf Attachment 10 -- HC MEPS Change of Address Card	IC Document
Attachment 11 -- HC MEPS Data Example & FAQs.doc Attachment 11 -- HC MEPS Data Example & FAQs	IC Document
Attachment 12 -- HC Rd 1 Prenotification Letter.doc Attachment 12 -- HC Rd 1 Prenotification Letter	IC Document
Attachment 13 -- HC Rd 1 Respondent Materials Cover Letter.doc Attachment 13 -- HC Rd 1 Respondent Materials Cover Letter	IC Document
Attachment 14 -- HC Rd 3 Advance Letter 1.doc Attachment 14 -- HC Rd 3 Advance Letter 1	IC Document
Attachment 15 -- HC Rd 3 Advance Letter 2.doc Attachment 15 -- HC Rd 3 Advance Letter 2	IC Document
Attachment 16 -- HC Rd 5 Advance Letter 1.doc Attachment 16 -- HC Rd 5 Advance Letter 1	IC Document
Attachment 17 -- HC Rd 5 Advance Letter 2.doc Attachment 17 -- HC Rd 5 Advance Letter 2	IC Document
Attachment 18 -- HC Rds 2 & 4 Advance Letter.doc Attachment 18 -- HC Rds 2 & 4 Advance Letter	IC Document
Attachment 19 -- HC MEPS FAQs Brochure.doc Attachment 19 -- HC MEPS FAQs Brochure	IC Document
Attachment 20 -- HC MEPS Monthly Planner.pdf Attachment 20 -- HC MEPS Monthly Planner	IC Document
Attachment 21 -- HC MEPS Record Keeper.pdf Attachment 21 -- HC MEPS Record Keeper	IC Document
Attachment 23 -- HC Showcards.doc Attachment 23 -- HC Showcards	IC Document
Attachment 24 -- HC Sorry I Missed You Note.pdf Attachment 24 -- HC Sorry I Missed You Note	IC Document
Attachment 25 -- HC Thank You Note.pdf Attachment 25 -- HC Thank You Note	IC Document
Attachment 26 -- HC Validation Letter.doc Attachment 26 -- HC Validation Letter	IC Document
Attachment 27 -- HC Users of MEPS Data Handout.doc Attachment 27 -- HC Users of MEPS Data Handout	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

MEPS-HC Core Interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-CAPI Specs	Attachment 33 -- HC Child Preventive Health Supplement Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 34 -- HC Condition Enumeration Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 35 -- HC Dental Care Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 36 -- HC Disability Days Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 37 -- HC Emergency Room Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 38 -- HC Employment Driver Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 39 -- HC Employment Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 40 -- HC Employment Wage Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 41 -- HC Event Roster Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 42 -- HC Flat Fee Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 43 -- HC Health Insurance Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 46 -- HC Hospital Stay Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 44 -- HC Health Status Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 45 -- HC Home Health Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 47 -- HC Income Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 48 -- HC Managed Care Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 49 -- HC Medical Provider Visits Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 50 -- HC Old Employment & Private Related Insurance Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 51 -- HC Old Public Related Insurance Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 52 -- HC Other Medical Expenses Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 53 -- HC Outpatient Department Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 54 -- HC Prescribed Medicines Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 55 -- HC Preventive Care Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 56 -- HC Priority Conditions Enumeration Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 57 -- HC Private Health Insurance Detail Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 28 -- HC Access to Care Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 29 -- HC Accident, Injury & Conditions Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 30 -- HC Assets Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 31 -- HC Calendar Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 32 -- HC Charge Payment Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 65 -- HC Satisfaction with Health Plan Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 66 -- HC Time Period Covered Detail Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 67 -- HC Information Screen Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 68 -- HC F1 Help Text.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 69 -- HC Closing Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 58 -- HC Provider Directory Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 59 -- HC Provider Probes Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 60 -- HC Provider Roster Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 61 -- HC Quality (Priority Conditions) Supplement Section.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 62 -- HC Reenumeration Subsection A.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 63 -- HC Reenumeration Subsection B.doc	Yes	Yes	Fillable Fileable
Other-CAPI Specs	Attachment 64 -- HC Review of Employment Information Section.doc	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	37,500	37,500
Annual IC Time Burden (Hours)	56,250	56,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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