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Federal forms, ICRs, and supporting documents

Information Collection

MEPS-HC Core Interview

IC 37877 under ICR 202406-0935-002 · OMB 0935-0118.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 1
MEPS-HC Core Interview		 Form and Instruction
Form 1
Access to Care MEPS-HC Core Interview		 Form and Instruction
Form 2
Additional Health Questions MEPS-HC Core Interview		 Form and Instruction
Form 3
Assets MEPS-HC Core Interview		 Form and Instruction
Form 4
Calendar Section MEPS-HC Core Interview		 Form and Instruction
Form 5
Closing Section MEPS-HC Core Interview		 Form and Instruction
Form 6
Contacting Module Section MEPS-HC Core Interview		 Form and Instruction
Form 7
Charge Payment Section MEPS-HC Core Interview		 Form and Instruction
Form 8
Child Preventive Health Section MEPS-HC Core Interview		 Form and Instruction
Form 9
Dental Visit Section MEPS-HC Core Interview		 Form and Instruction
Form 10
Event Driver Section MEPS-HC Core Interview		 Form and Instruction
Form 11
Event Enumeration Section MEPS-HC Core Interview		 Form and Instruction
Form 12
Event Follow-Up Section MEPS-HC Core Interview		 Form and Instruction
Form 13
Employment Section MEPS-HC Core Interview		 Form and Instruction
Form 14
Employment Driver Section MEPS-HC Core Interview		 Form and Instruction
Form 15
Emergency Room Section MEPS-HC Core Interview		 Form and Instruction
Form 16
Event Roster Section MEPS-HC Core Interview		 Form and Instruction
Form 17
Employment Wages Section MEPS-HC Core Interview		 Form and Instruction
Form 18
Flat Fee Section MEPS-HC Core Interview		 Form and Instruction
Form 19
Food Security Section MEPS-HC Core Interview		 Form and Instruction
Form 20
Global Section MEPS-HC Core Interview		 Form and Instruction
Form 21
Health Status Section MEPS-HC Core Interview		 Form and Instruction
Form 22
Home Health Section MEPS-HC Core Interview		 Form and Instruction
Form 23
Health Insurance Detail Section MEPS-HC Core Interview		 Form and Instruction
Form 24
Time Period Covered Detail Section MEPS-HC Core Interview		 Form and Instruction
Form 25
Hospital Stay Section MEPS-HC Core Interview		 Form and Instruction
Form 26
Health Insurance Section MEPS-HC Core Interview		 Form and Instruction
Form 27
Institutional Care Stay Section MEPS-HC Core Interview		 Form and Instruction
Form 28
Income Section MEPS-HC Core Interview		 Form and Instruction
Form 29
Institutional Care Section MEPS-HC Core Interview		 Form and Instruction
Form 30
Medical Visit Section MEPS-HC Core Interview		 Form and Instruction
Form 31
Old Employment-Private Related Insurance Section MEPS-HC Core Interview		 Form and Instruction
Form 32
Off Path Navigation Section MEPS-HC Core Interview		 Form and Instruction
Form 33
Other Medical Expenses Section MEPS-HC Core Interview		 Form and Instruction
Form 34
Outpatient Department Section MEPS-HC Core Interview		 Form and Instruction
Form 35
Priority Condition Section MEPS-HC Core Interview		 Form and Instruction
Form 36
Prescribed Medicines Section MEPS-HC Core Interview		 Form and Instruction
Form 37
Provider Probes Section MEPS-HC Core Interview		 Form and Instruction
Form 38
Old Public Related Insurance Section MEPS-HC Core Interview		 Form and Instruction
Form 39
Provider Roster Section MEPS-HC Core Interview		 Form and Instruction
Form 40
Quality Supplement Section MEPS-HC Core Interview		 Form and Instruction
Form 41
Reenumeration A Section MEPS-HC Core Interview		 Form and Instruction
Form 42
Reenumeration B Section MEPS-HC Core Interview		 Form and Instruction
Form 43
Respondent Forms Section MEPS-HC Core Interview		 Form and Instruction
Form 44
Review of Employment Section MEPS-HC Core Interview		 Form and Instruction
Form 45
Start-Restart Section MEPS-HC Core Interview		 Form and Instruction
Form 46
Telehealth Section MEPS-HC Core Interview		 Form and Instruction
1 Access to Care
Attachment 1 -- Access to Care.pdf 		Form and Instruction
1 Access to Care
Attachment 1 -- Access to Care.pdf 		Form and Instruction
2 Additional Health Questions
Attachment 2 -- Additional Healthcare Questions.pdf 		Form and Instruction
2 Additional Health Questions
Attachment 2 -- Additional Healthcare Questions.pdf 		Form and Instruction
3 Assets
Attachment 3 -- Assets.pdf 		Form and Instruction
3 Assets
Attachment 3 -- Assets.pdf 		Form and Instruction
4 Calendar Section
Attachment 4 -- Calendar Section.pdf 		Form and Instruction
4 Calendar Section
Attachment 4 -- Calendar Section.pdf 		Form and Instruction
5 Closing Section
Attachment 5 -- Closing Section.pdf 		Form and Instruction
5 Closing Section
Attachment 5 -- Closing Section.pdf 		Form and Instruction
6 Contacting Module Section
Attachment 6 -- Contacting Module Section.pdf 		Form and Instruction
6 Contacting Module Section
Attachment 6 -- Contacting Module Section.pdf 		Form and Instruction
7 Charge Payment Section
Attachment 7 -- Charge Payment Section.pdf 		Form and Instruction
7 Charge Payment Section
Attachment 7 -- Charge Payment Section.pdf 		Form and Instruction
8 Child Preventive Health Section
Attachment 8 -- Child Preventive Health Section.pdf 		Form and Instruction
8 Child Preventive Health Section
Attachment 8 -- Child Preventive Health Section.pdf 		Form and Instruction
9 Dental Visit Section
Attachment 9 -- Dental Visit Section.pdf 		Form and Instruction
9 Dental Visit Section
Attachment 9 -- Dental Visit Section.pdf 		Form and Instruction
10 Event Driver Section
Attachment 10 -- Event Driver Section.pdf 		Form and Instruction
10 Event Driver Section
Attachment 10 -- Event Driver Section.pdf 		Form and Instruction
11 Event Enumeration Section
Attachment 11 -- Event Enumeration Section.pdf 		Form and Instruction
11 Event Enumeration Section
Attachment 11 -- Event Enumeration Section.pdf 		Form and Instruction
12 Event Follow-Up Section
Attachment 12 -- Event Follow-Up Section.pdf 		Form and Instruction
12 Event Follow-Up Section
Attachment 12 -- Event Follow-Up Section.pdf 		Form and Instruction
13 Employment Section
Attachment 13 -- Employment Section.pdf 		Form and Instruction
13 Employment Section
Attachment 13 -- Employment Section.pdf 		Form and Instruction
14 Employment Driver Section
Attachment 14 -- Employment Driver Section.pdf 		Form and Instruction
14 Employment Driver Section
Attachment 14 -- Employment Driver Section.pdf 		Form and Instruction
15 Emergency Room Section
Attachment 15 -- Emergency Room Section.pdf 		Form and Instruction
15 Emergency Room Section
Attachment 15 -- Emergency Room Section.pdf 		Form and Instruction
16 Event Roster Section
Attachment 16 -- Event Roster Section.pdf 		Form and Instruction
16 Event Roster Section
Attachment 16 -- Event Roster Section.pdf 		Form and Instruction
17 Employment Wages Section
Attachment 17 -- Employment Wages Section.pdf 		Form and Instruction
17 Employment Wages Section
Attachment 17 -- Employment Wages Section.pdf 		Form and Instruction
18 Flat Fee Section
Attachment 18 -- Flat Fee Section.pdf 		Form and Instruction
18 Flat Fee Section
Attachment 18 -- Flat Fee Section.pdf 		Form and Instruction
19 Food Security Section
Attachment 19 -- Food Security Section.pdf 		Form and Instruction
19 Food Security Section
Attachment 19 -- Food Security Section.pdf 		Form and Instruction
20 Global Section
Attachment 20 -- Global Section.pdf 		Form and Instruction
20 Global Section
Attachment 20 -- Global Section.pdf 		Form and Instruction
21 Health Status Section
Attachment 21 - Health Status Section.pdf 		Form and Instruction
21 Health Status Section
Attachment 21 - Health Status Section.pdf 		Form and Instruction
22 Home Health Section
Attachment 22 -- Home Health Section.pdf 		Form and Instruction
22 Home Health Section
Attachment 22 -- Home Health Section.pdf 		Form and Instruction
23 Health Insurance Detail Section
Attachment 23 -- Health Insurance Detail Section.pdf 		Form and Instruction
23 Health Insurance Detail Section
Attachment 23 -- Health Insurance Detail Section.pdf 		Form and Instruction
24 Time Period Covered Detail Section
Attachment 24 -- Time Period Covered Detail Section.pdf 		Form and Instruction
24 Time Period Covered Detail Section
Attachment 24 -- Time Period Covered Detail Section.pdf 		Form and Instruction
25 Hospital Stay Section
Attachment 25 -- Hospital Stay Section.pdf 		Form and Instruction
25 Hospital Stay Section
Attachment 25 -- Hospital Stay Section.pdf 		Form and Instruction
26 Health Insurance Section
Attachment 26 -- Health Insurance Section.pdf 		Form and Instruction
26 Health Insurance Section
Attachment 26 -- Health Insurance Section.pdf 		Form and Instruction
27 Institutional Care Stay Section
Attachment 27 -- Institutional Care Stay Section.pdf 		Form and Instruction
27 Institutional Care Stay Section
Attachment 27 -- Institutional Care Stay Section.pdf 		Form and Instruction
28 Income Section
Attachment 28 -- Income Section.pdf 		Form and Instruction
28 Income Section
Attachment 28 -- Income Section.pdf 		Form and Instruction
29 Institutional Care Section
Attachment 29 -- Institutional Care Section.pdf 		Form and Instruction
29 Institutional Care Section
Attachment 29 -- Institutional Care Section.pdf 		Form and Instruction
30 Medical Visit Section
Attachment 30 -- Medical Visit Section.pdf 		Form and Instruction
30 Medical Visit Section
Attachment 30 -- Medical Visit Section.pdf 		Form and Instruction
31 Old Employment-Private Related Insurance Section
Attachment 31 -- Old Empl-Priv Related Ins Section.pdf 		Form and Instruction
31 Old Employment-Private Related Insurance Section
Attachment 31 -- Old Empl-Priv Related Ins Section.pdf 		Form and Instruction
32 Off Path Navigation Section
Attachment 32 -- Off Path Navigation Section.pdf 		Form and Instruction
32 Off Path Navigation Section
Attachment 32 -- Off Path Navigation Section.pdf 		Form and Instruction
33 Other Medical Expenses Section
Attachment 33 -- Other Medical Expenses Section.pdf 		Form and Instruction
33 Other Medical Expenses Section
Attachment 33 -- Other Medical Expenses Section.pdf 		Form and Instruction
34 Outpatient Department Section
Attachment 34 -- Outpatient Department Section.pdf 		Form and Instruction
34 Outpatient Department Section
Attachment 34 -- Outpatient Department Section.pdf 		Form and Instruction
35 Priority Condition Section
Attachment 35 -- Priority Condition Enumeration Section.pdf 		Form and Instruction
35 Priority Condition Section
Attachment 35 -- Priority Condition Enumeration Section.pdf 		Form and Instruction
36 Prescribed Medicines Section
Attachment 36 -- Prescribed Medicines Section.pdf 		Form and Instruction
36 Prescribed Medicines Section
Attachment 36 -- Prescribed Medicines Section.pdf 		Form and Instruction
37 Provider Probes Section
Attachment 37 -- Provider Probes Section.pdf 		Form and Instruction
37 Provider Probes Section
Attachment 37 -- Provider Probes Section.pdf 		Form and Instruction
38 Old Public Related Insurance Section
Attachment 38 -- Old Public Related Insurance Section.pdf 		Form and Instruction
38 Old Public Related Insurance Section
Attachment 38 -- Old Public Related Insurance Section.pdf 		Form and Instruction
39 Provider Roster Section
Attachment 39 -- Provider Roster Section.pdf 		Form and Instruction
39 Provider Roster Section
Attachment 39 -- Provider Roster Section.pdf 		Form and Instruction
40 Quality Supplement Section
Attachment 40 -- Quality Supplement Section.pdf 		Form and Instruction
40 Quality Supplement Section
Attachment 40 -- Quality Supplement Section.pdf 		Form and Instruction
41 Reenumeration A Section
Attachment 41 -- Reenumeration A Section.pdf 		Form and Instruction
41 Reenumeration A Section
Attachment 41 -- Reenumeration A Section.pdf 		Form and Instruction
42 Reenumeration B Section
Attachment 42 -- Reenumeration B Section.pdf 		Form and Instruction
42 Reenumeration B Section
Attachment 42 -- Reenumeration B Section.pdf 		Form and Instruction
43 Respondent Forms Section
Attachment 43 -- Respondent Forms Section.pdf 		Form and Instruction
43 Respondent Forms Section
Attachment 43 -- Respondent Forms Section.pdf 		Form and Instruction
44 Review of Employment Section
Attachment 44 -- Review of Employment Section.pdf 		Form and Instruction
44 Review of Employment Section
Attachment 44 -- Review of Employment Section.pdf 		Form and Instruction
45 Start-Restart Section
Attachment 45 -- Start-Restart Section.pdf 		Form and Instruction
45 Start-Restart Section
Attachment 45 -- Start-Restart Section.pdf 		Form and Instruction
46 Telehealth Section
Attachment 46 -- Telehealth Section.pdf 		Form and Instruction
46 Telehealth Section
Attachment 46 -- Telehealth Section.pdf 		Form and Instruction
Attachment 47 - MEPS-HC Show Cards.pdf
MEPS-HC Show Cards		IC Document
Attachment 47 - MEPS-HC Show Cards.pdf
MEPS-HC Show Cards		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 No   Fillable Fileable
Form and Instruction 2 Yes Yes Fillable Fileable
Form and Instruction 3 Yes Yes Fillable Fileable
Form and Instruction 4 Yes Yes Fillable Fileable
Form and Instruction 5 Yes Yes Fillable Fileable
Form and Instruction 6 Yes Yes Fillable Fileable
Form and Instruction 7 Yes Yes Fillable Fileable
Form and Instruction 8 Yes Yes Fillable Fileable
Form and Instruction 9 Yes Yes Fillable Fileable
Form and Instruction 10 Yes Yes Fillable Fileable
Form and Instruction 11 Yes Yes Fillable Fileable
Form and Instruction 12 Yes Yes Fillable Fileable
Form and Instruction 13 Yes Yes Fillable Fileable
Form and Instruction 14 Yes Yes Fillable Fileable
Form and Instruction 15 Yes Yes Fillable Fileable
Form and Instruction 16 Yes Yes Fillable Fileable
Form and Instruction 17 Yes Yes Fillable Fileable
Form and Instruction 18 Yes Yes Fillable Fileable
Form and Instruction 19 Yes Yes Fillable Fileable
Form and Instruction 20 Yes Yes Fillable Fileable
Form and Instruction 21 Yes Yes Fillable Fileable
Form and Instruction 22 Yes Yes Fillable Fileable
Form and Instruction 23 Yes Yes Fillable Fileable
Form and Instruction 24 Yes Yes Fillable Fileable
Form and Instruction 25 Yes Yes Fillable Fileable
Form and Instruction 26 Yes Yes Fillable Fileable
Form and Instruction 27 Yes Yes Fillable Fileable
Form and Instruction 28 Yes Yes Fillable Fileable
Form and Instruction 29 Yes Yes Fillable Fileable
Form and Instruction 30 Yes Yes Fillable Fileable
Form and Instruction 31 Yes Yes Fillable Fileable
Form and Instruction 32 Yes Yes Fillable Fileable
Form and Instruction 33 Yes Yes Fillable Fileable
Form and Instruction 34 Yes Yes Fillable Fileable
Form and Instruction 35 Yes Yes Fillable Fileable
Form and Instruction 36 Yes Yes Fillable Fileable
Form and Instruction 37 Yes Yes Fillable Fileable
Form and Instruction 38 Yes Yes Fillable Fileable
Form and Instruction 39 Yes Yes Fillable Fileable
Form and Instruction 40 Yes Yes Fillable Fileable
Form and Instruction 41 Yes Yes Fillable Fileable
Form and Instruction 42 Yes Yes Fillable Fileable
Form and Instruction 43 Yes Yes Fillable Fileable
Form and Instruction 44 Yes Yes Fillable Fileable
Form and Instruction 45 Yes Yes Fillable Fileable
Form and Instruction 46 Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 31,708 0 2,333 0 0 29,375
Annual IC Time Burden (Hours) 46,505 0 3,422 0 0 43,083
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
MEPS-HC Show Cards 07/01/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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