Establishment Questionnaire

2012 and 2013 Medical Expenditure Panel Survey - Insurance Componenet (MEPS-IC)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0110 can be found here:

Documents and Forms

Document Name Document Type
Form Form #2 Establishment Questionnaire Form and Instruction
Form #2 Attachment B -- Establishment Questionnaire -- Revised ATTACHMENT B -- Establishment Questionnaire -- Revised.pdf Form and Instruction
ATTACHMENT B -- Establishment Questionnaire -- Currently Approved.pdf ATTACHMENT B -- Establishment Questionnaire -- Currently Approved IC Document

Information Collection (IC) Details

IC Title:	Establishment 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 #2	Attachment B -- Establishment Questionnaire -- Revised	ATTACHMENT B -- Establishment Questionnaire -- Revised.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25,839	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions, Farms

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25,839	25,839
Annual IC Time Burden (Hours)	9,819	9,819
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
ATTACHMENT B -- Establishment Questionnaire -- Currently Approved	ATTACHMENT B -- Establishment Questionnaire -- Currently Approved.pdf	03/21/2013

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