NHDS - Primary Procedures Hospital Transmittal Notice

OMB No. 0920-0212: Approval Expires 08/31/2008
FORM HDS-3
(9-12-2005)

U.S. DEPARTMENT OF COMMERCE

1. Date of
transmittal

Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

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

TRANSMITTAL NOTICE

2. Hospital
number
3. Regional
Office
5. This shipment includes –
(Complete separate form for each data
month)

National Hospital Discharge Survey
4. Hospital name and address

Month

Number of records

Year

a. Data month/year: ____________________

b. Back records

c. Total number of
records transmitted
6. BACK RECORDS SUBMITTED (If applicable)

7. RECORDS NOT AVAILABLE (If applicable)

HDS number

Medical record
number

HDS number

Medical record
number

HDS number

Medical record
number

HDS number

Medical record
number

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

8. CHANGES – Mark (X) appropriate box. Indicate the changes if the "YES" is marked.
New Abstractor/
Full name
New Management
Yes
Information System
(MIS) contact
No
9. Sources of data abstraction:

10. REQUEST FOR ADDITIONAL BLANK FORMS
(Enter quantity for each item needed)

Reabstracted from printouts

Item —

Abstracted by hospital personnel

HDS-1, Medical Abstracts

Title

Quantity

Abstracted by Census personnel
Acceptable printout

HDS-5, Sample Listing Sheets
HDS-3, Transmittal Notices
BC-356, Transmittal Envelopes

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 1 minute 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).
Copy distribution: WHITE – Hospital

YELLOW – NCHS Processing

PINK – Regional Office

GOLDENROD – Field Representative