Information Collection

Attachment C – Social and Health Experiences Self-Administered Questionnaire

IC 242879 under ICR 202401-0935-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form Attachment C 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
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
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 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 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 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
Attachment F1 AHRQ response to Brookings Letter.docx Attachment F1 - AHRQ Response to Brookings	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Attachment C â Social and Health Experiences Self-Administered Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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
	Program Change Due to Agency Discretion	Previously Approved
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		07/29/2020
Attachment E â Public Comments: Academy of Nutrition and Dietetics		07/29/2020
Attachment E1 â AHRQ Response to Academy of Nutrition and Dietetics		07/29/2020
Attachment F â Public Comments: Brookings		07/29/2020
Attachment F1 - AHRQ Response to Brookings		07/29/2020

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

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