Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)

Forms and Documents

Document Name	Status
Form Form #1 MEPS-HC Core Interview Form	Modified
Form Form #1 MPC Contact Guide/Screening Call Form and Instruction	New
Form Form #1 MEPS-HC Validation Interview Form and Instruction	New
Form Form #1 Authorization form for the MEPS-MPC Pharmacy Survey Form and Instruction	New
Form Form #1 Authorization form for the MEPS-MPC Provider Survey Form and Instruction	New
Form Form #12 Experiences with Cancer SAQ Form and Instruction	Removed
Form Form #1 Pharmacies questionnaire Form and Instruction	Modified
Form Form #1 Institutions (non-hospital) questionnaire Form and Instruction	Modified
Form Form #1 Hospitals questionnaire Form and Instruction	Modified
Form Form #1 Separately billing doctors questionnaire Form and Instruction	Modified
Form Form #1 Office based providers questionnaire Form and Instruction	Modified
Form Form #1 Home care for non health care providers questionnaire Form and Instruction	Modified
Form Form #1 Home care for health care providers questionnaire Form and Instruction	Modified
Form Form #4 Permission Forms for the MEPS-MPC Form and Instruction	Removed
Form Form #1 Diabetes Care SAQ Form and Instruction	Modified
Form Form #1 Adult SAQ Form and Instruction	Modified
Supporting Statement Part B -- MEPS HC and MPC 8-28-2012.doc Supporting Statement B	2012-09-24
Attachment 51 -- MPC Pharmacy Respondent Materials - Phone Version.doc Supplementary Document	2012-09-24
Attachment 50 -- MPC Pharmacy Respondent Materials - FAX Version.doc Supplementary Document	2012-09-24
Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version.doc Supplementary Document	2012-09-24
Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version.doc Supplementary Document	2012-09-24
Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version.doc Supplementary Document	2012-09-24
Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version.doc Supplementary Document	2012-09-24
Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version.doc Supplementary Document	2012-09-24
Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version.doc Supplementary Document	2012-09-24
Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version.doc Supplementary Document	2012-09-24
Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version.doc Supplementary Document	2012-09-24
Attachment 39 -- MPC SBD Respondent Materials - Phone Version.doc Supplementary Document	2012-09-24
Attachment 38 -- MPC SBD Respondent Materials - Fax Version.doc Supplementary Document	2012-09-24
Attachment 34 -- MPC Office Based Respondent Materials - Phone Version.doc Supplementary Document	2012-09-24
Attachment 33 -- MPC Office Based Respondent Materials - FAX Version.doc Supplementary Document	2012-09-24
Attachment 31 -- MPC Home Health Respondent Materials - Phone Version.doc Supplementary Document	2012-09-24
Attachment 30 -- MPC Home Health Respondent Materials - FAX Version.doc Supplementary Document	2012-09-24
Attachment 31 -- MPC Home Health Respondent Materials - Phone Version.doc Supplementary Document	2012-09-24
Attachment 30 -- MPC Home Health Respondent Materials - FAX Version.doc Supplementary Document	2012-09-24
Attachment 15 -- HC MEPS Monthly Planner 2013-2014.zip Supplementary Document	2012-09-24
Attachment 6 -- HC Statistical Brief Abstracts.zip Supplementary Document	2012-09-24
Attachment 7 -- HC About the MEPS-MPC Authorization Form.zip Supplementary Document	2012-09-24
Attachment 20 -- HC Who Uses MEPS Data.docx Supplementary Document	2012-09-24
Attachment 19 -- HC Certificate of Appreciation.docx Supplementary Document	2012-09-24
Attachment 18 -- HC Validation Letter.doc Supplementary Document	2012-09-24
Attachment 17 -- HC Showcards 2013.doc Supplementary Document	2012-09-24
Attachment 16 -- HC MEPS Record Keeper.pdf Supplementary Document	2012-09-24
Attachment 14 -- HC MEPS FAQs Brochure.docx Supplementary Document	2012-09-24
Attachment 13 -- HC Respondent Letters, Postcards and Notes.docx Supplementary Document	2012-09-24
Attachment 12 -- HC MEPS Data Example & FAQs.docx Supplementary Document	2012-09-24
Attachment 11 -- HC Important Information About Your Participation in MEPS.doc Supplementary Document	2012-09-24
Attachment 10 -- HC Respondent Recruitment DVD.docx Supplementary Document	2012-09-24
Attachment 9 -- HC DVD Companion Booklet.docx Supplementary Document	2012-09-24
Attachment 8 -- HC Data protection is word ONE with MEPS.doc Supplementary Document	2012-09-24
Attachment 5 -- HC MEPS A Survey of Health Care Use and Spending.docx Supplementary Document	2012-09-24
Attachment 4 -- HC Policy Impact Award.doc Supplementary Document	2012-09-24
Attachment 3 -- HC Why is Participation in MEPS so Important.pdf Supplementary Document	2012-09-24
Attachment 2 -- HC About MEPS Booklet.docx Supplementary Document	2012-09-24
Supporting Statement Part A -- MEPS HC and MPC 9-17-2012.doc Supporting Statement A	2012-09-24

IC Document Collections

IC ID	Document Title	Status
37877	MEPS-HC Core Interview Form	Modified
204200	MPC Contact Guide/Screening Call Form and Instruction	New
204199	MEPS-HC Validation Interview Form and Instruction	New
204198	Authorization form for the MEPS-MPC Pharmacy Survey Form and Instruction	New
204197	Authorization form for the MEPS-MPC Provider Survey Form and Instruction	New
200754	Experiences with Cancer SAQ Form and Instruction	Removed
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	Modified
191101	Home care for health care providers questionnaire Form and Instruction	Modified
191100	Permission Forms for the MEPS-MPC Form and Instruction	Removed
191099	Diabetes Care SAQ Form and Instruction	Modified
191098	Adult SAQ Form and Instruction	Modified

ICR Details

OMB Control No: 0935-0118	ICR Reference No: 201209-0935-001
Status: Historical Active	Previous ICR Reference No: 201201-0935-001
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/20/2012
	Date Received in OIRA: 09/25/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved	02/28/2015
Responses	505,956	0	463,686
Time Burden (Hours)	82,822	0	83,858
Cost Burden (Dollars)	0	0	0

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Abstract: The MEPS includes the collection of data from household and medical providers to provide nationally representative unbiased estimates of health care use and expenditures for the U.S. civilian noninstitutionalized population.

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Authorizing Statute(s): US Code: 9 USC 580 Name of Law: Agency for Healthcare Research and Quality
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 35399	06/13/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 58386	09/20/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 14

IC Title	Form No.	Form Name
MEPS-HC Core Interview	Form #1	Attachment 1 -- MEPS-HC Section Summary and Changes
Adult SAQ	Form #1	Attachment 21 -- HC Adult SAQ
Diabetes Care SAQ	Form #1, Form #2	Attachment 22 -- HC Diabetes SAQ - Proxy ,   Attachment 23 -- HC Diabetes SAQ - Self
Home care for health care providers questionnaire	Form #1	Home care for health care providers questionnaire
Home care for non health care providers questionnaire	Form #1	Home care for non health care providers questionnaire
Office based providers questionnaire	Form #1	Office based providers questionnaire
Separately billing doctors questionnaire	Form #1	Separately billing doctors questionnaire
Hospitals questionnaire	Form #1	Hospitals questionnaire
Institutions (non-hospital) questionnaire	Form #1	Institutions (non-hospital) questionnaire
Pharmacies questionnaire	Form #1	Pharmacies questionnaire
Authorization form for the MEPS-MPC Provider Survey	Form #1	Authorization Form for the MEPS-MPC - Provider
Authorization form for the MEPS-MPC Pharmacy Survey	Form #1	Authorization form for the MEPS-MPC Pharmacy Survey
MEPS-HC Validation Interview	Form #1	Validation Interview Form
MPC Contact Guide/Screening Call	Form #1, Form #2, Form #3, Form #4, Form #5, Form #6	Home Health Contact Guide for Organizations ,   Office Based Contact Guide ,   SBD Contact Guide ,   Hospital Contact Guide ,   Institution Contact Guide ,   Pharmacy Contact Guide
Permission Forms for the MEPS-MPC	Form #4, Form #5	Pharmacy Form ,   Provider Form
Experiences with Cancer SAQ	Form #12	Experiences with Cancer SAQ

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	505,956	463,686	0	42,270	0	0
Annual Time Burden (Hours)	82,822	83,858	0	-1,036	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The total estimated annual burden hours for the MEPS have been increased from 82,767 hours in the previous clearance to 82,821hours in this clearance request, an increase of 54 hours, or 0.0007%.

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Annual Cost to Federal Government: $51,401,596

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/25/2012

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