Information Collection

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

IC 226530 under ICR 201409-0935-002 · OMB 0935-0124.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	B1	Attachment B â 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 %

table that charts list of burden
	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

table that charts IC Documents
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 â Agency for Healthcare Research and Quality (AHRQ) Mission	Attachment A --- Healthcare Research and Quality Act of 1999.pdf	04/24/2017
Attachment C2 â Cognitive Interview Show Cards	Attachment C_2 Cognitive Interview Showcards.docx	04/24/2017
Attachment C3 â Cognitive Interview Enumeration Template	Attachment C_3 Cognitive Interview Enumeration Template.docx	04/24/2017
Attachment D1 â Thank You (General Population)	Attachment D_1 Thank You General Population.docx	04/24/2017
Attachment D2 â Thank You (U.S. Armed Services)	Attachment D_2 Thank You US Armed Services.docx	04/24/2017
Attachment D3 â Thank You (Medical Assistance)	Attachment D_3 Thank You Medical Assistance.docx	04/24/2017
Attachment D4 â Thank You (Affordable Care Act)	Attachment D_4 Thank You Affordable Care Act.docx	04/24/2017
Attachment D5 â Invitation/Recruitment Letter	Attachment D_5 Invitation_Recruitment Letter.docx	04/24/2017
Attachment E â Respondent consent form	Attachment E Respondent Consent Form.docx	04/24/2017
Attachment F â 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.