Attachment C – Social and Health Experiences Self-Administered Questionnaire

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⚠️ Notice: This information collection may be referencing outdated material.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 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

Information Collection (IC) Details

IC Title:	Attachment C – 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:

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 %

	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

Title	Document	Date Uploaded
Attachment D – 60 Day FRN	60 Day FRN.pdf	07/29/2020
Attachment E – 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 – AHRQ Response to Academy of Nutrition and Dietetics	Attachment E1 AHRQ Response to AND.msg	07/29/2020
Attachment F – 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.