Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments

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⚠️ Notice: This information collection may be referencing outdated material.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 3 Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments Form and Instruction
3 Attachment G – Focus Group Protocol Attachment G - Focus Group Protocol Local Gov.docx Form and Instruction
1 Screening Attachment A Initial Screening Questionnaire Private Ins.docx Form and Instruction
2 In Depth Screening Attachment B In-depth Screening Questionnaire Private Ins.docx Form and Instruction
Attachment C – Informational Letter for Participants Local Gov.docx Attachment C – Informational Letter for Participants IC Document
Attachment D – Participant Consent Form Local Gov.docx Attachment D – Participant Consent Form IC Document
Attachment E – Directions to Econometrica Facility Local Gov.docx Attachment E – Directions to Econometrica Facility IC Document
Attachment F - Checklist and Directions for Gathering Requested Documents Local Gov.docx Attachment F – Checklist and Directions for Gathering Requested Documents IC Document
OMB Cover Letter.doc Cover Letter IC Document
Supporting Statement A Health Policy Booklets Local Gov 031119.docx Supporting Statement A Health Policy Booklets Local Government IC Document

Information Collection (IC) Details

IC Title:	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments	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?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Attachment G – Focus Group Protocol	Attachment G - Focus Group Protocol Local Gov.docx	No		Paper Only
Form and Instruction	1	Screening	Attachment A Initial Screening Questionnaire Private Ins.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	In Depth Screening	Attachment B In-depth Screening Questionnaire Private Ins.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 240	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	23	23
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment C – Informational Letter for Participants	Attachment C – Informational Letter for Participants Local Gov.docx	01/11/2019
Attachment D – Participant Consent Form	Attachment D – Participant Consent Form Local Gov.docx	01/11/2019
Attachment E – Directions to Econometrica Facility	Attachment E – Directions to Econometrica Facility Local Gov.docx	01/11/2019
Attachment F – Checklist and Directions for Gathering Requested Documents	Attachment F - Checklist and Directions for Gathering Requested Documents Local Gov.docx	01/11/2019
Cover Letter	OMB Cover Letter.doc	01/11/2019
Supporting Statement A Health Policy Booklets Local Government	Supporting Statement A Health Policy Booklets Local Gov 031119.docx	04/08/2019

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