Information Collection

MEPS Alternative Sampling Design Pilot Test

IC 252822 under ICR 202401-0935-006 · OMB 0935-0124.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 MEPS Alternative Sampling Design Pilot Test	Form and Instruction
1 Pilot Screener Attachment A.docx	Form and Instruction
1 Pilot Screener Attachment A.docx	Form and Instruction
Cover Letter.docx Cover Letter	IC Document
Cover Letter.docx Cover Letter	IC Document
Attachment B.docx Attachment B – Pilot Mailing Materials	IC Document
Attachment B.docx Attachment B – Pilot Mailing Materials	IC Document
SS A clean.docx Supporting Statement Part A	IC Document
SS A clean.docx Supporting Statement Part A	IC Document
SS B Clean.docx Supporting Statement Part B	IC Document
SS B Clean.docx Supporting Statement Part B	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 Screener	Attachment A.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,393

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	3,393	3,393
Annual IC Time Burden (Hours)	567	567
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter	Cover Letter.docx	04/11/2022
Attachment B â Pilot Mailing Materials	Attachment B.docx	04/11/2022
Supporting Statement Part A	SS A clean.docx	05/24/2022
Supporting Statement Part B	SS B Clean.docx	05/24/2022

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