NHAMCS-101(C) National Hospital Ambulatory Medical Care Survey -- 2009

a code and No.)

Form Approved OMB No. 0920-0278: Expires 8/31/2009 CDC 64-151

NHAMCS-101(C)

Label

FORM
(6-17-2008)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Health Statistics

NATIONAL HOSPITAL
AMBULATORY MEDICAL
CARE SURVEY
2009 PANEL
CONTROL CARD
Assurance of Confidentiality – All informatin which would permit identification of an individual a practice, or an
establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when
required and with necessary controls, and will not be disclosed or released to other persons without the consent
of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC
242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
2a. Hospital Contact
Information
Name

2c. OPD Contact
Information

2b. ED Contact Information

2d. ASC Contact
Information

Name

Name

Name

Title

Title

Title

Title

Telephone No. (Area code
and No.)

Telephone No. (Area code
and No.)

Telephone No. (Area code
and No.)

Telephone No. (Area code
and No.)

FAX number

FAX number

FAX number

FAX number

Section I – TELEPHONE SCREENER
7a. Correct hospital name
7b. Correct hospital
location

Number and Street
City

7c. Correct hospital
mailing address

State

ZIP Code

State

ZIP Code

Hospital name
Number and Street
City

10c. Person responsible
for hospital’s
emergency
response plan

ZIP Code

Number and Street
City

8g. Name and address
of other hospital to
which merged or
separated

State

CONTACT INFORMATION
Name
Title
Telephone (Area code and number)
CONTINUE ON REVERSE

a code and No.)

Section II – INDUCTION INTERVIEW
Name

13. Sampling Contacts Where "Someone Else" Entered on NHAMCS-101
Name

Title

Title

Department

Department

Telephone number

Telephone number

Section III – EMERGENCY DEPARTMENT DESCRIPTION,
Section IV – OUTPATIENT DEPARTMENT DESCRIPTION AND Section V – AMBULATORY SURGERY
CENTER DESCRIPTION FORMAL ESA/OPD CLINIC NAMES BRIDGE
INSTRUCTIONS – List below ONLY ESAs/Clinics/ASC that have formal/proper names (e.g., John Smith
Emergency Department). Their display in Sections III, IV, and on the NHAMCS-101 could breach confidentiality
by providing a means to track the name and address of the hospital, ESA, clinic or ASC. Use a generic name on
the NHAMCS-101 (e.g., Obstetrics) and enter the formal name on the line below, indicating the "Line No." where
the ESA/Clinic/ASC is found on the NHAMCS-101 (e.g., Line No. 1 – Jane Doe Obstetrics Clinic).
Section III – EMERGENCY SERVICE AREA (ESA)
Line
No.

Notes

FORM NHAMCS-101(C) (6-17-2008)

ESA Name

Section IV – OUTPATIENT DEPARTMENT CLINIC
Line
No.

Clinic Name