Information Collection

Attachment C – Social and Health Experiences Self-Administered Questionnaire

IC 242879 under ICR 202007-0935-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Attachment C Attachment C – Social and Health Experiences Self-Administered Questionnaire	Form and Instruction
Attachment C Attachment C Attachment C. SDOH SAQ_paper draft 4_to AHRQ.docx	Form and Instruction
60 Day FRN.pdf Attachment D – 60 Day FRN	IC Document
Attachment E Academy of Nutrition and Dietetics_MEPS Social and Health Experiences SAQ.pdf Attachment E – Public Comments: Academy of Nutrition and Dietetics	IC Document
Attachment E1 AHRQ Response to AND.msg Attachment E1 – AHRQ Response to Academy of Nutrition and Dietetics	IC Document
Attachment F Brookings AHRQ survey comments May 2020 - Graham.docx Attachment F – Public Comments: Brookings	IC Document
Attachment F1 AHRQ response to Brookings Letter.docx Attachment F1 - AHRQ Response to Brookings	IC Document

IC Title:

Attachment C â Social and Health Experiences Self-Administered Questionnaire

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	Attachment C	Attachment C	Attachment C. SDOH SAQ_paper draft 4_to AHRQ.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 27,059

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	27,059	27,059
Annual IC Time Burden (Hours)	3,157	3,157
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment D â 60 Day FRN	60 Day FRN.pdf	07/29/2020
Attachment E â Public Comments: Academy of Nutrition and Dietetics	Attachment E Academy of Nutrition and Dietetics_MEPS Social and Health Experiences SAQ.pdf	07/29/2020
Attachment E1 â AHRQ Response to Academy of Nutrition and Dietetics	Attachment E1 AHRQ Response to AND.msg	07/29/2020
Attachment F â Public Comments: Brookings	Attachment F Brookings AHRQ survey comments May 2020 - Graham.docx	07/29/2020
Attachment F1 - AHRQ Response to Brookings	Attachment F1 AHRQ response to Brookings Letter.docx	07/29/2020

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