OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Medical Expenditure Panel Survey - Household and Medical Provider Components

ICR 202401-0935-001 · OMB 0935-0118 · Received in OIRA

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 2a Cancer SAQ Form and Instruction New Repair queued
Form 5a Preventive Care SAQ Form and Instruction New Repair queued
Form 1a Adult SAQ Form and Instruction New Repair queued
Form 1 COVID-19 Questions Form and Instruction Removed Repair queued
Form Attachment A – COV COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire Form and Instruction Removed Repair queued
Form Attachment C Attachment C – Social and Health Experiences Self-Administered Questionnaire Form and Instruction Removed Repair queued
Form 106a HC Adult SAQ that includes Mental Health Questions Form and Instruction Removed Repair queued
Form 107a Health Insurance Cost Sharing Collection- 2020 Form and Instruction Removed Repair queued
Form 108 Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Form and Instruction Removed Repair queued
Form Attachment 19 Attachment 19 – HC Adult SAQ – Male Form and Instruction Removed Missing upstream
Form Attachment 20 Attachment 20 HC Adult SAQ Female Form and Instruction Removed Repair queued
Form Attachment 72 MPC Contact Guide/Screening Call Form and Instruction Modified Missing upstream
Form Attachment 26 MEPS-HC Validation Interview Form and Instruction Modified Repair queued
Form Attachment 24 Authorization form for the MEPS-MPC Pharmacy Survey Form and Instruction Removed Missing upstream
Form Attachment 25 Authorization form for the MEPS-MPC Provider and Pharmacy Survey Form and Instruction Modified Repair queued
Form Attachment 98 Pharmacies questionnaire Form and Instruction Modified Available
Form Attachment 96 Institutions (non-hospital) questionnaire Form and Instruction Modified Missing upstream
Form Attachment 91 Hospitals questionnaire Form and Instruction Modified Missing upstream
Form Attachment 87 Separately billing doctors questionnaire Form and Instruction Modified Missing upstream
Form Attachment 83 Office based providers questionnaire Form and Instruction Modified Repair queued
Form Attachment 82 Home care for non health care providers questionnaire Form and Instruction Removed Missing upstream
Form 4a Home Care Providers Event Form Form and Instruction Modified Repair queued
Form Attachment 22 Diabetes Care SAQ Form and Instruction Modified Repair queued
SS Part A - MEPS-HC MPC 01122024.docx Supporting Statement A Uploaded 2024-01-12 Repair queued
SS Part B - MEPS HC MPC - 2024.docx Supporting Statement B Uploaded 2024-01-09 Repair queued
Attachment 6 - Federal Register Notice.pdf Supplementary Document Uploaded 2024-01-09 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
37877 MEPS-HC Core Interview Other-Explanatory Modified
264332 Cancer SAQ Form and Instruction New
264315 Preventive Care SAQ Form and Instruction New
264201 Adult SAQ Form and Instruction New
256163 COVID-19 Questions Form and Instruction Removed
242880 COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire Form and Instruction Removed
242879 Attachment C – Social and Health Experiences Self-Administered Questionnaire Form and Instruction Removed
236894 HC Adult SAQ that includes Mental Health Questions Form and Instruction Removed
236893 Health Insurance Cost Sharing Collection- 2020 Form and Instruction Removed
236883 Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Form and Instruction Removed
230227 Attachment 19 – HC Adult SAQ – Male Form and Instruction Removed
230226 Attachment 20 HC Adult SAQ Female Form and Instruction Removed
204200 MPC Contact Guide/Screening Call Form and Instruction Modified
204199 MEPS-HC Validation Interview Form and Instruction Modified
204198 Authorization form for the MEPS-MPC Pharmacy Survey Form and Instruction Removed
204197 Authorization form for the MEPS-MPC Provider and Pharmacy Survey Form and Instruction Modified
191107 Pharmacies questionnaire Form and Instruction Modified
191106 Institutions (non-hospital) questionnaire Form and Instruction Modified
191105 Hospitals questionnaire Form and Instruction Modified
191104 Separately billing doctors questionnaire Form and Instruction Modified
191103 Office based providers questionnaire Form and Instruction Modified
191102 Home care for non health care providers questionnaire Form and Instruction Removed
191101 Home Care Providers Event Form Form and Instruction Modified
191099 Diabetes Care SAQ Form and Instruction Modified

ICR Details

Record metadata
StatusReceived in OIRA
Agency/SubagencyHHS/AHRQ
OMB Control No0935-0118
Type of Information CollectionRevision of a currently approved collection
Previous ICR Reference No202209-0935-003
Date Submitted to OIRA1969-12-31
Requested Expiration Date1969-12-31