Information Collection

Office-based Physicians eligible/Patient Record Form

IC 181890 under ICR 200901-0920-007 · OMB 0920-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Document Name Document Type
NAHMCS Questionnaire.doc Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Office-based Physicians eligible/Patient Record Form	Agency IC Tracking Number:

Is this a Common Form?		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
Instruction			NAHMCS Questionnaire.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,008	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	60,240	60,240
Annual IC Time Burden (Hours)	5,020	5,020
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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