Attachment 20 HC Adult SAQ Female

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⚠️ Notice: This information collection may be referencing outdated material.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 Attachment 19 Attachment 20 HC Adult SAQ Female Form and Instruction
Attachment 20 Attachment 20 HC Adult SAQ Female Attachment 20 HC Adult SAQ Female.docx Form and Instruction
Attachment 19 Attachment 19 HC Adult SAQ Male Attachment 19 HC Adult SAQ Male.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment 20 HC Adult SAQ Female	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Attachment 19	Attachment 19 HC Adult SAQ Male	Attachment 19 HC Adult SAQ Male.docx		No		Fillable Fileable
Form and Instruction	Attachment 20	Attachment 20 HC Adult SAQ Female	Attachment 20 HC Adult SAQ Female.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,984	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,984	-1,708	14,692
Annual IC Time Burden (Hours)	1,515	-199	1,714
Annual IC Cost Burden (Dollars)	0	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.