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

Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality

Documents and Forms

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
1 Pilot test – Establishment Questionnaire meps10_033121 v2.pdf Form and Instruction
2 Pilot test – Plan Questionnaire meps10s_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
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 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
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
2021 Survey Forms-20D.pdf 2021 Forms 20D IC Document

Information Collection (IC) Details

IC Title:	Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component	Agency IC Tracking Number:

IC Status: Unchanged

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	1	Pilot test – Establishment Questionnaire	meps10_033121 v2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	2	Pilot test – 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 %

	Requested	Previously Approved
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

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.