NCHS National Ambulatory Medical Care Survey

Forms and Documents

Document Name	Status
Form unnumbered Lab Pretest Patient Record Form Form	Modified
Form unnumbered Lab Values Pretest Induction form Form	New
Form unnumbered Electronic Medical Record/Electronic Health Record Mail Survey Form Form	New
Form unnumbered Community Health Center Induction Interview Form Form	New
Form unnumbered Office-Based Physicians eligible/Cervical Cancer Screening Supplement Form	Modified
Form unnumbered Office-based Physicians eligible/Patient Record Form Form	Modified
Form unnumbered Office-based physicians /Physician Induction Interview Form	Modified
NAMCS 09-12 OMB SS-B REV final 040609.doc Supporting Statement B	2009-04-27
Revised Attachment B submitted June 11.doc Supplementary Document	2009-06-11
NAMCS 09-12 OMB ATT P.pdf Supplementary Document	2009-05-11
NAMCS 09-12 OMB ATT M.pdf Supplementary Document	2009-05-11
NAMCS 09-12 rev REV 30day 050809 rev x.doc Supplementary Document	2009-05-11
NAMCS 09-12 OMB ATT Q.pdf Supplementary Document	2009-05-11
NAMCS 09-12 Attachment E.pdf Supplementary Document	2009-05-07
NAMCS 09-12 OMB ATT C.pdf Supplementary Document	2009-05-07
NAMCS 09-12 Attachment D.pdf Supplementary Document	2009-05-07
NAMCS 09-12 OMB ATT A.pdf Supplementary Document	2009-04-27
NAMCS 09-12 OMB ATT L.pdf Supplementary Document	2009-04-27
NAMCS 09-12 OMB ATT R.pdf Supplementary Document	2009-05-11
NAMCS 09-12 OMB ATT S.pdf Supplementary Document	2009-05-11
NAMCS 09-12 Attachment H.pdf Supplementary Document	2009-05-11
NAMCS 09-12 Attachment G.pdf Supplementary Document	2009-06-04
NAMCS 09-12 OMB SS-A (3) 051109.doc Supporting Statement A	2009-05-12

IC Document Collections

IC ID	Document Title	Status
43612	Lab Pretest Patient Record Form Form	Modified
189599	Lab Values Pretest Induction form Form	New
189598	Electronic Medical Record/Electronic Health Record Mail Survey Form Form	New
189597	Community Health Center Induction Interview Form Form	New
181893	Office-Based Physicians ineligible/Physician Induction Interview Instruction	Removed
181892	Office-Based Physicians eligible/Cervical Cancer Screening Supplement Form	Modified
181891	Office-Based Physicians eligible/Pulling and Re-filing Patient Record Form Instruction	Modified
181890	Office-based Physicians eligible/Patient Record Form Form	Modified
181889	Office-based physicians /Physician Induction Interview Form	Modified

ICR Details

OMB Control No: 0920-0234	ICR Reference No: 200906-0920-008
Status: Historical Active	Previous ICR Reference No: 200905-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: NCHS National Ambulatory Medical Care Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/09/2009
	Date Received in OIRA: 06/16/2009
Terms of Clearance: NCHS and OMB note that, should sufficient funding become available, it would be useful to add a quality assurance component that includes re-abstraction of medical records in the field. OMB also requests that NCHS explore more systematically the implications of the under-representation of larger, higher volume practices on the reported results (e.g., trends in care), and within six months, discuss your findings with our study design experts whether weighting might be in order.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2012	36 Months From Approved	08/31/2009
Responses	47,271	0	75,886
Time Burden (Hours)	5,932	0	7,207
Cost Burden (Dollars)	0	0	0

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Abstract: Data collected from office-based physicians, and community health center providers, concerning patient visits are aggregated to national statistics. This request will permit NAMCS to collect again in 2009 electronic medical record data that had been approved for collection in 2008. In addition, a pretest examining laboratory values on tests commonly ordered to monitor cardiovascular fitness, diabetes management, and diabetes detection is also requested.

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Authorizing Statute(s): US Code: 42 USC 242K Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 5660	01/30/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 22935	05/15/2009
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Lab Values Pretest Induction form	unnumbered	Lab Values Pretest Induction form
Office-Based Physicians ineligible/Physician Induction Interview
Office-based physicians /Physician Induction Interview	unnumbered	Physician Induction Interview (Line 1)
Office-based Physicians eligible/Patient Record Form	unnumbered	Patient Record Form
Office-Based Physicians eligible/Pulling and Re-filing Patient Record Form
Office-Based Physicians eligible/Cervical Cancer Screening Supplement	unnumbered	Cervical Cancer Screening Supplement (Att. U)
Community Health Center Induction Interview Form	unnumbered	Community Health Center Induction Interview
Electronic Medical Record/Electronic Health Record Mail Survey Form	unnumbered	EMR/EHR Mail Survey form
Lab Pretest Patient Record Form	unnumbered	Att. I Lab Pretest Patient Record form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	47,271	75,886	0	-28,615	0	0
Annual Time Burden (Hours)	5,932	7,207	0	-1,275	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The overall burden for the revised project is decreased due to: (1) a more complete review of the documents, (2) the time to complete them has changed, and (3) a slightly different calculation method that took into account the 2006 data as proxies for physician/provider responses. However, some forms are new or have an increase in burden.

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Annual Cost to Federal Government: $4,724,608

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/16/2009

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