Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module

Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality

OMB: 0935-0124

IC ID: 226530

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0124 can be found here:

Documents and Forms

Document Name Document Type
Form B1 Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module Form and Instruction
B1 Attachment B – Screening Questionnaire Attachment B Screening Questionnaire.docx Form and Instruction
C1 Attachment C1 - Cognitive Interview Guide and Questionna Attachment C__1 Cognitive Interview Guide and Questionnaire.docx Form and Instruction
Supporting Statement Part A -- Cognitive Testing for MEPS.docx Supporting Statement Part A IC Document
Supporting Statement Part B --.docx Supporting Statement Part B IC Document
Attachment A --- Healthcare Research and Quality Act of 1999.pdf Attachment A – Agency for Healthcare Research and Quality (AHRQ) Mission IC Document
Attachment C_2 Cognitive Interview Showcards.docx Attachment C2 – Cognitive Interview Show Cards IC Document
Attachment C_3 Cognitive Interview Enumeration Template.docx Attachment C3 – Cognitive Interview Enumeration Template IC Document
Attachment D_1 Thank You General Population.docx Attachment D1 – Thank You (General Population) IC Document
Attachment D_2 Thank You US Armed Services.docx Attachment D2 – Thank You (U.S. Armed Services) IC Document
Attachment D_3 Thank You Medical Assistance.docx Attachment D3 – Thank You (Medical Assistance) IC Document
Attachment D_4 Thank You Affordable Care Act.docx Attachment D4 – Thank You (Affordable Care Act) IC Document
Attachment D_5 Invitation_Recruitment Letter.docx Attachment D5 – Invitation/Recruitment Letter IC Document
Attachment E Respondent Consent Form.docx Attachment E – Respondent consent form IC Document
OMB Cover Letter.docx.doc Attachment F – OMB Cover Letter IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module	Agency IC Tracking Number:

IC Status: New

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	B1	Attachment B – Screening Questionnaire	Attachment B Screening Questionnaire.docx		No		Fillable Fileable
Form and Instruction	C1	Attachment C1 - Cognitive Interview Guide and Questionnaire	Attachment C__1 Cognitive Interview Guide and Questionnaire.docx		No		Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 444	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	444	444
Annual IC Time Burden (Hours)	77	77
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement Part A	Supporting Statement Part A -- Cognitive Testing for MEPS.docx	04/24/2017
Supporting Statement Part B	Supporting Statement Part B --.docx	04/24/2017
Attachment A – Agency for Healthcare Research and Quality (AHRQ) Mission	Attachment A --- Healthcare Research and Quality Act of 1999.pdf	04/24/2017
Attachment C2 – Cognitive Interview Show Cards	Attachment C_2 Cognitive Interview Showcards.docx	04/24/2017
Attachment C3 – Cognitive Interview Enumeration Template	Attachment C_3 Cognitive Interview Enumeration Template.docx	04/24/2017
Attachment D1 – Thank You (General Population)	Attachment D_1 Thank You General Population.docx	04/24/2017
Attachment D2 – Thank You (U.S. Armed Services)	Attachment D_2 Thank You US Armed Services.docx	04/24/2017
Attachment D3 – Thank You (Medical Assistance)	Attachment D_3 Thank You Medical Assistance.docx	04/24/2017
Attachment D4 – Thank You (Affordable Care Act)	Attachment D_4 Thank You Affordable Care Act.docx	04/24/2017
Attachment D5 – Invitation/Recruitment Letter	Attachment D_5 Invitation_Recruitment Letter.docx	04/24/2017
Attachment E – Respondent consent form	Attachment E Respondent Consent Form.docx	04/24/2017
Attachment F – OMB Cover Letter	OMB Cover Letter.docx.doc	04/24/2017

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