OPD Patient Record Form

National Hospital Ambulatory Medical Care Survey

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form NHMACS 100 (OPD) OPD Patient Record Form Form
NHMACS 100 (OPD) OPD Patient Record Form NHAMCS Attach O 2009 100od .pdf Form
NHAMCS Att O Cover sheet 2009 100(OD).doc Coversheet IC Document

Information Collection (IC) Details

IC Title:	OPD 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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NHMACS 100 (OPD)	OPD Patient Record Form	NHAMCS Attach O 2009 100od .pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health Resources Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 125	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	25,000	1,250	23,750
Annual IC Time Burden (Hours)	2,500	125	2,375
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Coversheet	NHAMCS Att O Cover sheet 2009 100(OD).doc	07/24/2008

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