National Hospital Ambulatory Medical Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form NHAMCS-101/U Ambulatory Unit Induction	Form and Instruction	Modified	Available
Form NHMACS 100 (OPD) OPD Patient Record Form	Form	Modified	Available
Form NHAMCS 100 (ASC) ASC Patient Record Form	Form and Instruction	Modified	Available
Form NHAMCS 100 (ED) ED Patient Record Form	Form	Modified	Available
Form NHAMCS-101 Hospital Induction	Form and Instruction	Modified	Repair queued
Form NHAMCS-906 Cervical Cancer Screening Supplement	Form	Modified	Available
NHAMCS SS B 062708.doc	Supporting Statement B	Uploaded 2008-07-23	Available
NHAMCS Att S 2009 intro letter 61708.doc	Supplementary Document	Uploaded 2008-07-23	Repair queued
Attach Q NHAMCS123 Outpatient Department Clinic Instruction Booklet.pdf	Supplementary Document	Uploaded 2008-07-23	Available
Attach P NHAMCS122 Emergency Service Area Instruction Booklet.pdf	Supplementary Document	Uploaded 2008-07-23	Available
NHAMCS Attach M 2009 124 .pdf	Supplementary Document	Uploaded 2008-09-08	Available
Attach L NHAMCS - Visit Log.pdf	Supplementary Document	Uploaded 2008-07-23	Available
Attach I NHAMCS - Endorsing Letters.pdf	Supplementary Document	Uploaded 2008-07-23	Available
Attach H NHAMCS - Intrductory Letters to NHAMCS Hospitals.pdf	Supplementary Document	Uploaded 2008-07-23	Available
NHAMCS Att G IRB Letter.doc	Supplementary Document	Uploaded 2008-07-23	Available
Attach F NHAMCS 07 Consultants.doc	Supplementary Document	Uploaded 2008-07-23	Available
Attach E NHAMCS OMB 60 day notice.pdf	Supplementary Document	Uploaded 2008-07-23	Available
Attach D - NHAMCS ADR Computerized Clinical Support.pdf	Supplementary Document	Uploaded 2008-07-23	Available
Attach C NHAMCS Bioterrorism-Advanced Data Report.pdf	Supplementary Document	Uploaded 2008-07-23	Available
Attach B NHAMCS List of Publications.pdf	Supplementary Document	Uploaded 2008-07-23	Available
Attach A NHAMCS Public Health Service Act.pdf	Supplementary Document	Uploaded 2008-07-23	Available
NHAMCS Att O Cover sheet 2009 100(OD).doc	Supplementary Document	Uploaded 2008-07-24	Available
NHAMCS Att T Cover sheet 2009 Revised100(ASC).doc	Supplementary Document	Uploaded 2008-07-24	Available
NHAMCS Att N Cover sheet 2009 100(ED).doc	Supplementary Document	Uploaded 2008-07-23	Available
NHAMCS Att J Cover sheet 2009 Revised101 (3)072208.doc	Supplementary Document	Uploaded 2008-07-24	Available
NHAMCS Att K Cover sheet 2009x Revised101u (2).doc	Supplementary Document	Uploaded 2008-07-23	Available
NHAMCS SS A Rev 090208 .doc	Supporting Statement A	Uploaded 2008-09-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43613	Ambulatory Unit Induction	Form and Instruction	Modified
181869	Medical Record Clerk/ Pulling and re-filing OPD Patient Record	Instruction	Removed
181868	Pulling and re-filing Patient Records	Instruction	Modified
181867	OPD Patient Record Form	Form	Modified
181866	ASC Patient Record Form	Form and Instruction	Modified
181865	ED Patient Record Form	Form	Modified
181864	Hospital Induction	Form and Instruction	Modified
181863	Cervical Cancer Screening Supplement	Form	Modified

ICR Details

OMB Control No: 0920-0278	ICR Reference No: 200808-0920-007
Status: Historical Active	Previous ICR Reference No: 200801-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Hospital Ambulatory Medical Care Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/08/2008
	Date Received in OIRA: 08/25/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2010	08/31/2009	08/31/2009
Responses	111,986	0	90,031
Time Burden (Hours)	9,186	0	7,312
Cost Burden (Dollars)	0	0	0

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Abstract: NHMACS data are currently collected from hospital emergency and outpatient departments, concerning facilities and patient visits, and are aggregaed to national statistics. This change will permit NHAMCS to collect in-hospital ambulatory surgery data in 2009. This data had been collected under 0920-0234.

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Authorizing Statute(s): US Code: 42 USC 306 Name of Law: Public Health Service Act
  

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:
	71 FR 2045	01/12/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 45011	08/01/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Cervical Cancer Screening Supplement	NHAMCS-906	Cervical Cancer Screening Supplement
Ambulatory Unit Induction	NHAMCS-101/U	Ambulatory Unit Induction
Hospital Induction	NHAMCS-101	Hospital Induction
ED Patient Record Form	NHAMCS 100 (ED)	ED Patient Record Form
ASC Patient Record Form	NHAMCS 100 (ASC)	ASC Patient Record Form
OPD Patient Record Form	NHMACS 100 (OPD)	OPD Patient Record Form
Pulling and re-filing Patient Records
Medical Record Clerk/ Pulling and re-filing OPD Patient Record

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ICR Summary of Burden

table that charts list 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	111,986	90,031	0	21,955	0	0
Annual Time Burden (Hours)	9,186	7,312	0	1,874	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: This revision will permit NHAMCS to collect in-hospital ambulatory surgery data in 2009. Data had been collected under 0920-0334.

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Annual Cost to Federal Government: $4,963,000

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

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: 08/21/2008

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