Attachment J Pretest Sample Listing Sheet NHDS Redesign OMB No. 0920-0212: Approval expires 08/31/2008
Notice - Public reporting burden for this collection of information is estimated to average 14 minutes per response, including 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 burden to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0212).
Assurances of Confidentiality – All information which would permit identification of any 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 the 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).
ATTACHMENT J
PRETEST
SAMPLE LISTING SHEET
NHDS REDESIGN
Sample Listing Sheet for the Pretest
Hospital name
Hospital identification number (internal NHDS use)
Sampling period (month sampling performed)
Number of discharges sampled during this period
Name of person performing sampling
Date sampling performed
Hospital Statistics:
Hospital NOT in business during sampling period
Hospital Statistics for Sampling Strata (for June and July 2008):
Total number of observation stays
Number of observation stays sampled
Total number of normal newborn infants
Number of normal newborn infants sampled
Total number of discharges with acute myocardial infarction (AMI)
Number of AMIs sampled
Total number of inpatients discharged dead
Number of discharged dead sampled
HDS identification number
Date of discharge
Medical record number
Encounter number / billing number
Stratum from which discharge sampled
Date record abstracted
Out-of-scope reason
| File Type | application/msword |
| File Title | ATTACHMENT O |
| Author | Christine Lucas |
| Last Modified By | Christine Lucas |
| File Modified | 2008-07-15 |
| File Created | 2008-07-15 |