Information Collection

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

IC 234065 under ICR 201708-0935-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	Health Policy Booklets Supporting Statement A 2018.11.20V1.docx	11/20/2018
Attachment C â Informational Letter for Participants	Attachment C â Informational Letter for Participants.docx	11/20/2018
Attachment E â Directions to Econometrica Facility	Attachment E â Directions to Econometrica Facility.docx	11/20/2018
Attachment F â Checklist and Directions for Gathering Requested Documents	Attachment F â 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.