Information Collection

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

IC 246524 under ICR 202401-0935-006 · OMB 0935-0124.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

IC Status: Unchanged

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

table that charts list of burden
	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

table that charts IC Documents
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.