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Form #1 Form #1 Prescreener Questionnaire
Medical Expenditure Panel Survey - Insurance Component (MEPS-IC)
Attachment A - Prescreener Questionnaire
Prescreener Questionnaire
OMB: 0935-0110
OMB.report
HHS/AHRQ
OMB 0935-0110
ICR 202212-0935-001
IC 182459
Form #1 Form #1 Prescreener Questionnaire
( )
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0935-0110 can be found here:
2023-01-09 - Revision of a currently approved collection
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