Information Collection

Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component

IC 246524 under ICR 202009-0935-003 · OMB 0935-0124.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0124 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component	Form and Instruction
1 Pilot test – Establishment Questionnaire meps10_033121 v2.pdf	Form and Instruction
2 Pilot test – Plan Questionnaire meps10s_033121 v2.pdf	Form and Instruction
OMB Cover Letter.docx Cover Letter	IC Document
Supporting Statement Part A - Pilot test MEPS-IC_v2_052421.docx Supporting Statement Part A	IC Document
Supporting Statement Part B - Pilot Test of MEPS-IC Revised Data Collection Method - 3-24-2021 v2.docx Supporting Statement Part B	IC Document
2021 Survey Forms-20D.pdf 2021 Forms 20D	IC Document

IC Title:

Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component

Agency IC Tracking Number:

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	1	Pilot test â Establishment Questionnaire	meps10_033121 v2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	2	Pilot test â Plan Questionnaire	meps10s_033121 v2.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	1,180	1,180
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter	OMB Cover Letter.docx	03/31/2021
Supporting Statement Part A	Supporting Statement Part A - Pilot test MEPS-IC_v2_052421.docx	05/24/2021
Supporting Statement Part B	Supporting Statement Part B - Pilot Test of MEPS-IC Revised Data Collection Method - 3-24-2021 v2.docx	03/31/2021
2021 Forms 20D	2021 Survey Forms-20D.pdf	05/24/2021

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