Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Employer-sponsored Insurance Plans

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

⚠️ Notice: This information collection may be referencing outdated material.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 1 Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Employer-sponsored Insurance Plans Form and Instruction
1 Attachment A – Initial Screening Questionnaire Attachment A – Initial Screening Questionnaire.docx Form and Instruction
2 Attachment B – In-depth Screening Questionnaire Attachment B – In-depth Screening Questionnaire.docx Form and Instruction
3 Attachment D – Participant Consent Form Attachment D – Participant Consent Form.docx Form and Instruction
4 Attachment G – Focus Group Protocol Attachment G – Focus Group Protocol.docx Form and Instruction
Health Policy Booklets Supporting Statement A 2018.11.20V1.docx Supporting Statement IC Document
Attachment C – Informational Letter for Participants.docx Attachment C – Informational Letter for Participants IC Document
Attachment E – Directions to Econometrica Facility.docx Attachment E – Directions to Econometrica Facility IC Document
Attachment F – Checklist and Directions for Gathering Requested Documents.docx Attachment F – Checklist and Directions for Gathering Requested Documents IC Document
OMB Cover Letter.docx.doc Cover Letter IC Document

Information Collection (IC) Details

IC Title:	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Employer-sponsored Insurance Plans	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	1	Attachment A – Initial Screening Questionnaire	Attachment A – Initial Screening Questionnaire.docx	No	Fillable Fileable
Form and Instruction	2	Attachment B – In-depth Screening Questionnaire	Attachment B – In-depth Screening Questionnaire.docx	No	Paper Only
Form and Instruction	3	Attachment D – Participant Consent Form	Attachment D – Participant Consent Form.docx	No	Fillable Fileable
Form and Instruction	4	Attachment G – Focus Group Protocol	Attachment G – Focus Group Protocol.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 310	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	310	310
Annual IC Time Burden (Hours)	45	45
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Health Policy Booklets Supporting Statement A 2018.11.20V1.docx	11/20/2018
Attachment C – Informational Letter for Participants	Attachment C – Informational Letter for Participants.docx	11/20/2018
Attachment E – Directions to Econometrica Facility	Attachment E – Directions to Econometrica Facility.docx	11/20/2018
Attachment F – Checklist and Directions for Gathering Requested Documents	Attachment F – Checklist and Directions for Gathering Requested Documents.docx	11/20/2018
Cover Letter	OMB Cover Letter.docx.doc	11/20/2018

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