Preventive Care SAQ

Medical Expenditure Panel Survey - Household and Medical Provider Components

⚠️ Notice: This information collection may be referencing outdated material.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 5a Preventive Care SAQ Form and Instruction
5a Preventative Care SAQ Attachment 4 - PSAQ - fall 2024.pdf Form and Instruction
5a Preventative Care SAQ Attachment 4 - PSAQ - fall 2024.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Preventive Care SAQ	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	5a	Preventative Care SAQ	Attachment 4 - PSAQ - fall 2024.pdf		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,688	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,844	2,844
Annual IC Time Burden (Hours)	332	332
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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