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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #1 Attachment 1 -- MEPS-HC Section Summary and Changes	Form	Modified	Available
Form Form #6 Pharmacy Contact Guide	Form and Instruction	New	Available
Form Form #5 Institution Contact Guide	Form and Instruction	New	Available
Form Form #4 Hospital Contact Guide	Form and Instruction	New	Available
Form Form #3 SBD Contact Guide	Form and Instruction	New	Available
Form Form #2 Office Based Contact Guide	Form and Instruction	New	Available
Form Form #1 Home Health Contact Guide for Organizations	Form and Instruction	New	Available
Form Form #1 Validation Interview Form	Form and Instruction	New	Available
Form Form #1 Authorization form for the MEPS-MPC Pharmacy Survey	Form and Instruction	New	Available
Form Form #1 Authorization Form for the MEPS-MPC - Provider	Form and Instruction	New	Available
Form Form #12 Experiences with Cancer SAQ	Form and Instruction	Removed	Available
Form Form #1 Pharmacies questionnaire	Form and Instruction	Modified	Available
Form Form #1 Institutions (non-hospital) questionnaire	Form and Instruction	Modified	Available
Form Form #1 Hospitals questionnaire	Form and Instruction	Modified	Available
Form Form #1 Separately billing doctors questionnaire	Form and Instruction	Modified	Available
Form Form #1 Office based providers questionnaire	Form and Instruction	Modified	Available
Form Form #1 Home care for non health care providers questionnaire	Form and Instruction	Modified	Available
Form Form #1 Home care for health care providers questionnaire	Form and Instruction	Modified	Available
Form Form #5 Provider Form	Form and Instruction	Removed	Available
Form Form #4 Pharmacy Form	Form and Instruction	Removed	Available
Form Form #2 Attachment 23 -- HC Diabetes SAQ - Self	Form and Instruction	Modified	Available
Form Form #1 Attachment 22 -- HC Diabetes SAQ - Proxy	Form and Instruction	Modified	Available
Form Form #1 Attachment 21 -- HC Adult SAQ	Form and Instruction	Modified	Available
Supporting Statement Part B -- MEPS HC and MPC 8-28-2012.doc	Supporting Statement B	Uploaded 2012-09-24	Available
Attachment 51 -- MPC Pharmacy Respondent Materials - Phone Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 50 -- MPC Pharmacy Respondent Materials - FAX Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 39 -- MPC SBD Respondent Materials - Phone Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 38 -- MPC SBD Respondent Materials - Fax Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 34 -- MPC Office Based Respondent Materials - Phone Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 33 -- MPC Office Based Respondent Materials - FAX Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 31 -- MPC Home Health Respondent Materials - Phone Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 30 -- MPC Home Health Respondent Materials - FAX Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 31 -- MPC Home Health Respondent Materials - Phone Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 30 -- MPC Home Health Respondent Materials - FAX Version.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 15 -- HC MEPS Monthly Planner 2013-2014.zip	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 6 -- HC Statistical Brief Abstracts.zip	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 7 -- HC About the MEPS-MPC Authorization Form.zip	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 20 -- HC Who Uses MEPS Data.docx	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 19 -- HC Certificate of Appreciation.docx	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 18 -- HC Validation Letter.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 17 -- HC Showcards 2013.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 16 -- HC MEPS Record Keeper.pdf	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 14 -- HC MEPS FAQs Brochure.docx	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 13 -- HC Respondent Letters, Postcards and Notes.docx	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 12 -- HC MEPS Data Example & FAQs.docx	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 11 -- HC Important Information About Your Participation in MEPS.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 10 -- HC Respondent Recruitment DVD.docx	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 9 -- HC DVD Companion Booklet.docx	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 8 -- HC Data protection is word ONE with MEPS.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 5 -- HC MEPS A Survey of Health Care Use and Spending.docx	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 4 -- HC Policy Impact Award.doc	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 3 -- HC Why is Participation in MEPS so Important.pdf	Supplementary Document	Uploaded 2012-09-24	Available
Attachment 2 -- HC About MEPS Booklet.docx	Supplementary Document	Uploaded 2012-09-24	Available
Supporting Statement Part A -- MEPS HC and MPC 9-17-2012.doc	Supporting Statement A	Uploaded 2012-09-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
37877	MEPS-HC Core Interview	Form	Modified	Attachment 1 -- MEPS-HC Section Summary and Changes
204200	MPC Contact Guide/Screening Call	Form and Instruction	New	Pharmacy Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	New	Institution Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	New	Hospital Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	New	SBD Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	New	Office Based Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	New	Home Health Contact Guide for Organizations
204199	MEPS-HC Validation Interview	Form and Instruction	New	Validation Interview Form
204198	Authorization form for the MEPS-MPC Pharmacy Survey	Form and Instruction	New	Authorization form for the MEPS-MPC Pharmacy Survey
204197	Authorization form for the MEPS-MPC Provider Survey	Form and Instruction	New	Authorization Form for the MEPS-MPC - Provider
200754	Experiences with Cancer SAQ	Form and Instruction	Removed	Experiences with Cancer SAQ
191107	Pharmacies questionnaire	Form and Instruction	Modified	Pharmacies questionnaire
191106	Institutions (non-hospital) questionnaire	Form and Instruction	Modified	Institutions (non-hospital) questionnaire
191105	Hospitals questionnaire	Form and Instruction	Modified	Hospitals questionnaire
191104	Separately billing doctors questionnaire	Form and Instruction	Modified	Separately billing doctors questionnaire
191103	Office based providers questionnaire	Form and Instruction	Modified	Office based providers questionnaire
191102	Home care for non health care providers questionnaire	Form and Instruction	Modified	Home care for non health care providers questionnaire
191101	Home care for health care providers questionnaire	Form and Instruction	Modified	Home care for health care providers questionnaire
191100	Permission Forms for the MEPS-MPC	Form and Instruction	Removed	Provider Form
191100	Permission Forms for the MEPS-MPC	Form and Instruction	Removed	Pharmacy Form
191099	Diabetes Care SAQ	Form and Instruction	Modified	Attachment 23 -- HC Diabetes SAQ - Self
191099	Diabetes Care SAQ	Form and Instruction	Modified	Attachment 22 -- HC Diabetes SAQ - Proxy
191098	Adult SAQ	Form and Instruction	Modified	Attachment 21 -- HC Adult SAQ

ICR Details

OMB Control No: 0935-0118	ICR Reference No: 201209-0935-001
Status: Historical Active	Previous ICR Reference No: 201201-0935-001
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: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/20/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/25/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved	02/28/2015
Responses	505,956	0	463,686
Time Burden (Hours)	82,822	0	83,858
Cost Burden (Dollars)	0	0	0

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Abstract: The MEPS includes the collection of data from household and 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:
	77 FR 35399	06/13/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 58386	09/20/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 14

table that charts list of burden

IC Title	Form No.	Form Name
Adult SAQ	Form #1	Attachment 21 -- HC Adult SAQ
Authorization form for the MEPS-MPC Pharmacy Survey	Form #1	Authorization form for the MEPS-MPC Pharmacy Survey
Authorization form for the MEPS-MPC Provider Survey	Form #1	Authorization Form for the MEPS-MPC - Provider
Diabetes Care SAQ	Form #1, Form #2	Attachment 22 -- HC Diabetes SAQ - Proxy ,   Attachment 23 -- HC Diabetes SAQ - Self
Experiences with Cancer SAQ	Form #12	Experiences with Cancer SAQ
Home care for health care providers questionnaire	Form #1	Home care for health care providers questionnaire
Home care for non health care providers questionnaire	Form #1	Home care for non health care providers questionnaire
Hospitals questionnaire	Form #1	Hospitals questionnaire
Institutions (non-hospital) questionnaire	Form #1	Institutions (non-hospital) questionnaire
MEPS-HC Core Interview	Form #1	Attachment 1 -- MEPS-HC Section Summary and Changes
MEPS-HC Validation Interview	Form #1	Validation Interview Form
MPC Contact Guide/Screening Call	Form #1, Form #2, Form #3, Form #4, Form #5, Form #6	Home Health Contact Guide for Organizations ,   Office Based Contact Guide ,   SBD Contact Guide ,   Hospital Contact Guide ,   Institution Contact Guide ,   Pharmacy Contact Guide
Office based providers questionnaire	Form #1	Office based providers questionnaire
Permission Forms for the MEPS-MPC	Form #4, Form #5	Pharmacy Form ,   Provider Form
Pharmacies questionnaire	Form #1	Pharmacies questionnaire
Separately billing doctors questionnaire	Form #1	Separately billing doctors questionnaire

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ICR Summary of Burden

table that charts list 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	505,956	463,686	0	42,270	0	0
Annual Time Burden (Hours)	82,822	83,858	0	-1,036	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The total estimated annual burden hours for the MEPS have been increased from 82,767 hours in the previous clearance to 82,821hours in this clearance request, an increase of 54 hours, or 0.0007%.

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Annual Cost to Federal Government: $51,401,596

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: 09/25/2012

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