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⚠️ Notice: This information collection may be referencing outdated material.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 Plan Questionnaire ATTACHMENT C - Plan Questionnaire.pdf Form and Instruction

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	Plan Questionnaire	ATTACHMENT C - Plan Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23,813	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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	52,389	3,606	48,783
Annual IC Time Burden (Hours)	9,430	649	8,781
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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