Plan 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⚠️ Notice: This information collection may be referencing outdated material.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 #3 Plan Questionnaire Form and Instruction
Form #3 Attachment C -- Plan Questionnaire -- Revised ATTACHMENT C -- Plan Questionnaire -- Revised.pdf Form and Instruction
ATTACHMENT C -- Plan Questionnaire -- Currently Approved.pdf ATTACHMENT C -- Plan Questionnaire -- Currently Approved IC Document

Information Collection (IC) Details

IC Title:	Plan 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 #3	Attachment C -- Plan Questionnaire -- Revised	ATTACHMENT C -- Plan 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: 23,230	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	48,783	48,783
Annual IC Time Burden (Hours)	8,781	8,781
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
ATTACHMENT C -- Plan Questionnaire -- Currently Approved	ATTACHMENT C -- Plan 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.