Medical Expenditure Panel Survey - Household and Medical Provider Components

ICR 202401-0935-001

OMB: 0935-0118

Federal Form Document

Forms and Documents

Document Name	Status
Form 2a Cancer SAQ Form and Instruction	New
Form 5a Preventive Care SAQ Form and Instruction	New
Form 1a Adult SAQ Form and Instruction	New
Form 1 COVID-19 Questions Form and Instruction	Removed
Form Attachment A – COV COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire Form and Instruction	Removed
Form Attachment C Attachment C – Social and Health Experiences Self-Administered Questionnaire Form and Instruction	Removed
Form 106a HC Adult SAQ that includes Mental Health Questions Form and Instruction	Removed
Form 107a Health Insurance Cost Sharing Collection- 2020 Form and Instruction	Removed
Form 108 Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Form and Instruction	Removed
Form Attachment 19 Attachment 19 – HC Adult SAQ – Male Form and Instruction	Removed
Form Attachment 20 Attachment 20 HC Adult SAQ Female Form and Instruction	Removed
Form Attachment 72 MPC Contact Guide/Screening Call Form and Instruction	Modified
Form Attachment 26 MEPS-HC Validation Interview Form and Instruction	Modified
Form Attachment 24 Authorization form for the MEPS-MPC Pharmacy Survey Form and Instruction	Removed
Form Attachment 25 Authorization form for the MEPS-MPC Provider and Pharmacy Survey Form and Instruction	Modified
Form Attachment 98 Pharmacies questionnaire Form and Instruction	Modified
Form Attachment 96 Institutions (non-hospital) questionnaire Form and Instruction	Modified
Form Attachment 91 Hospitals questionnaire Form and Instruction	Modified
Form Attachment 87 Separately billing doctors questionnaire Form and Instruction	Modified
Form Attachment 83 Office based providers questionnaire Form and Instruction	Modified
Form Attachment 82 Home care for non health care providers questionnaire Form and Instruction	Removed
Form 4a Home Care Providers Event Form Form and Instruction	Modified
Form Attachment 22 Diabetes Care SAQ Form and Instruction	Modified
SS Part A - MEPS-HC MPC 01122024.docx Supporting Statement A	2024-01-12
SS Part B - MEPS HC MPC - 2024.docx Supporting Statement B	2024-01-09
Attachment 6 - Federal Register Notice.pdf Supplementary Document	2024-01-09

IC Document Collections

IC ID	Document Title	Status
37877	MEPS-HC Core Interview Other-Explanatory	Modified
264332	Cancer SAQ Form and Instruction	New
264315	Preventive Care SAQ Form and Instruction	New
264201	Adult SAQ Form and Instruction	New
256163	COVID-19 Questions Form and Instruction	Removed
242880	COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire Form and Instruction	Removed
242879	Attachment C – Social and Health Experiences Self-Administered Questionnaire Form and Instruction	Removed
236894	HC Adult SAQ that includes Mental Health Questions Form and Instruction	Removed
236893	Health Insurance Cost Sharing Collection- 2020 Form and Instruction	Removed
236883	Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Form and Instruction	Removed
230227	Attachment 19 – HC Adult SAQ – Male Form and Instruction	Removed
230226	Attachment 20 HC Adult SAQ Female Form and Instruction	Removed
204200	MPC Contact Guide/Screening Call Form and Instruction	Modified
204199	MEPS-HC Validation Interview Form and Instruction	Modified
204198	Authorization form for the MEPS-MPC Pharmacy Survey Form and Instruction	Removed
204197	Authorization form for the MEPS-MPC Provider and Pharmacy Survey Form and Instruction	Modified
191107	Pharmacies questionnaire Form and Instruction	Modified
191106	Institutions (non-hospital) questionnaire Form and Instruction	Modified
191105	Hospitals questionnaire Form and Instruction	Modified
191104	Separately billing doctors questionnaire Form and Instruction	Modified
191103	Office based providers questionnaire Form and Instruction	Modified
191102	Home care for non health care providers questionnaire Form and Instruction	Removed
191101	Home Care Providers Event Form Form and Instruction	Modified
191099	Diabetes Care SAQ Form and Instruction	Modified