Information Collection

Medical Record Abstraction

IC 178550 under ICR 200702-0920-001 · OMB 0920-0741.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0741 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix S.1 Medical Record Request Script & Fax.doc	Other-Medical Record Request Script
Appendix S.2 PRENATAL MR Form.doc Prenatal Chart Abstraction Form	IC Document
Appendix S.3 L&D MR Form.doc Labor & Delivery Chart Abstraction Form	IC Document
Appendix S.4 Neonatal MR Form.DOC Neonatal Medical Record Abstraction Form	IC Document
Appendix S.5 Pediatric MR Form.DOC Pediatric Chart Abstraction Form	IC Document

IC Title:

Medical Record Abstraction

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-Medical Record Request Script and Fax Letter			Appendix S.1 Medical Record Request Script & Fax.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 3,456

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	17,280	17,280
Annual IC Time Burden (Hours)	4,320	4,320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Prenatal Chart Abstraction Form	Appendix S.2 PRENATAL MR Form.doc	06/05/2007
Labor & Delivery Chart Abstraction Form	Appendix S.3 L&D MR Form.doc	06/05/2007
Neonatal Medical Record Abstraction Form	Appendix S.4 Neonatal MR Form.DOC	06/05/2007
Pediatric Chart Abstraction Form	Appendix S.5 Pediatric MR Form.DOC	06/05/2007

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