Information Collection

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

IC 234708 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⚠️ Notice: This information collection may be referencing outdated material.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 3 Attachment G – Focus Group Protocol Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments	Form and Instruction
Form 1 Screening Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments	Form and Instruction
Form 2 In Depth Screening 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

View Information Collection (IC)

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	No		Paper Only
Form and Instruction	1	Yes	Yes	Fillable Fileable
Form and Instruction	2	Yes	Yes	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: 240

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C â Informational Letter for Participants		01/11/2019
Attachment D â Participant Consent Form		01/11/2019
Attachment E â Directions to Econometrica Facility		01/11/2019
Attachment F â Checklist and Directions for Gathering Requested Documents		01/11/2019
Cover Letter		01/11/2019
Supporting Statement A Health Policy Booklets Local Government		04/08/2019

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

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