NHDS - Primary Procedure Hospitals Sample Listing Sheet

Sheet
OMB No. 0920-0212: Approval Expires 08/31/2008
of
Notice – All information which would permit identification of an individual or an establishment will be held confidential, will be used only by persons engaged in
and for the purposes of the survey, and will not be disclosed or released to other persons or used for any other purpose. Public reporting burden of this collection
of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta,
GA 30333, ATTN: PRA (0920-0212).

A. HOSPITAL

HDS-5

FORM
(9-12-2005)

1. Name
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

2. Number

U.S. CENSUS BUREAU

3. List used

ACTING AS COLLECTING AGENT FOR

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
NATIONAL CENTER FOR HEALTH STATISTICS

SAMPLE LISTING
SHEET

B. STATISTICAL DATA
1. Total beds
(excluding bassinets)

2. Total admissions
(excluding newborn)

3. Live births

4. Total discharges
(including newborn)
C. SAMPLING

NATIONAL HOSPITAL
DISCHARGE SURVEY

1. Month

2. Key

3. Number in sample

4. Sample selected by (Name and title)
Other identification

HDS
number

Date of
discharge
(or admission)

Medical record
number

(1)

(2)

(3)

Copy distribution:

WHITE – Hospital

Date

(4)
Number if needed
(such as patient ID, billing,
etc.)

YELLOW – NCHS Processing

PINK – Regional Office

Names if needed

Date abstracted
(or out-of scope
reason)
(5)

GOLDENROD – Field Representative