Information Collection

Attachment 4 -- Male Adult - SAQ

IC 230227 under ICR 201802-0935-002 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 - (02092018) Attachment 4 -- Male Adult - SAQ	Form and Instruction
4 - (02092018) Attachment 4 - (02092018) MEPS SAQ 2018 Male v2 (27694 - Draft, Traditional).pdf	Form and Instruction

IC Title:

Attachment 4 -- Male Adult - SAQ

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4 - (02092018)	Attachment 4 - (02092018)	MEPS SAQ 2018 Male v2 (27694 - Draft, Traditional).pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,562

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	13,562	13,562
Annual IC Time Burden (Hours)	1,582	1,582
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.