Diabetes Care SAQ

Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Document Name Document Type
Form Form #1 Diabetes Care SAQ Form and Instruction
Form #1 Attachment 19 -- HC Diabetes SAQ - Proxy 19-HC Diabetes SAQ - Proxy.docx Form and Instruction
Form #2 Attachment 20 -- HC Diabetes SAQ - Self 20-HC Diabetes SAQ - Self.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Diabetes Care SAQ	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Attachment 19 -- HC Diabetes SAQ - Proxy	19-HC Diabetes SAQ - Proxy.docx		Yes	Yes	Paper Only
Form and Instruction	Form #2	Attachment 20 -- HC Diabetes SAQ - Self	20-HC Diabetes SAQ - Self.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,345	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,345	2,345
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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