Information Collection

ASC Patient Record Form

IC 181866 under ICR 200808-0920-007 · OMB 0920-0278.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0278 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NHAMCS 100 (ASC) ASC Patient Record Form	Form and Instruction
NHAMCS 100 (ASC) ASC Patient Record Form NHAMCS Att T 2009 folio Revised-100(ASC).pdf	Form and Instruction
NHAMCS Att T Cover sheet 2009 Revised100(ASC).doc Coversheet	IC Document

IC Title:

ASC Patient Record Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form and Instruction	NHAMCS 100 (ASC)	ASC Patient Record Form	NHAMCS Att T 2009 folio Revised-100(ASC).pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utlization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 107

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	Previously Approved
Annual Number of Responses for this IC	10,700	9,744	956
Annual IC Time Burden (Hours)	1,070	114	956
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Coversheet	NHAMCS Att T Cover sheet 2009 Revised100(ASC).doc	07/24/2008

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