Institutions (non-hospital) 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⚠️ Notice: This information collection may be referencing outdated material.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 #1 Institutions (non-hospital) questionnaire Form and Instruction
Form #1 Institutions (non-hospital) questionnaire Attachment 46 -- MPC Institutions (non-hospital) Questionnaire.doc Form and Instruction
Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version.doc Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version IC Document
Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version.doc Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version IC Document
Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version.doc Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version IC Document
Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version.doc Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version IC Document

Information Collection (IC) Details

IC Title:	Institutions (non-hospital) questionnaire	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 #1	Institutions (non-hospital) questionnaire	Attachment 46 -- MPC Institutions (non-hospital) Questionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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	Previously Approved
Annual Number of Responses for this IC	150	42	108
Annual IC Time Burden (Hours)	13	4	9
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version	Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version.doc	09/24/2012
Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version	Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version.doc	09/24/2012
Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version	Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version.doc	09/24/2012
Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version	Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version.doc	09/24/2012

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