Preventive Care SAQ

Medical Expenditure Panel Survey - Household and Medical Provider Components

Documents and Forms

Document Name Document Type
Form 49 Preventive Care SAQ Form and Instruction
49 PSAQ Attachment 49 -- PSAQ.pdf Form and Instruction
49 PSAQ Attachment 49 -- PSAQ.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Preventive Care SAQ	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	49	PSAQ	Attachment 49 -- PSAQ.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,800	4,956	2,844
Annual IC Time Burden (Hours)	910	578	332
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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