National Hospital Ambulatory Medical Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form unnumbered Att. J. Ambulatory Unit Induction Form	Form	Modified	Available
Freestanding Ambulatory Surgery Centers Form	Form	Modified	Repair queued
Form unnumbered Att. N. OPD Patient Record Form	Form	Modified	Available
Form unnumbered Att. O. ASC Patient Record Form	Form	Modified	Available
Form unnumbered Att. M. ED Patient Record Form	Form	Modified	Available
Hospital Induction Form	Form	Modified	Available
Form unnumbered Att. T. Cervical Cancer Screening Supplement	Form	Modified	Available
JUSTIFICATION FOR CHANGE.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2009-12-28	Available
NHAMCS2010 Attachment R - NHAMCS-123.pdf	Supplementary Document	Uploaded 2009-06-08	Available
NHAMCS2010 Attachment S - NHAMCS-126.pdf	Supplementary Document	Uploaded 2009-06-08	Available
NHAMCS2010 Attachment Q - NHAMCS-122.pdf	Supplementary Document	Uploaded 2009-06-08	Available
NHAMCS2010 Attachment K - NHAMCS-103.pdf	Supplementary Document	Uploaded 2009-06-08	Available
NHAMCS 2010 NS Change supp Stat. 121709.doc	Supporting Statement A	Uploaded 2009-12-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43613	Ambulatory Unit Record	Form	Modified	Att. J. Ambulatory Unit Induction Form
189813	Freestanding ASC Induction Form	Form	Modified	Freestanding Ambulatory Surgery Centers Form
181868	Pulling and re-filing Patient Records	Instruction	Modified
181867	OPD Patient Record Form	Form	Modified	Att. N. OPD Patient Record Form
181866	ASC Patient Record Form	Form	Modified	Att. O. ASC Patient Record Form
181865	ED Patient Record Form	Form	Modified	Att. M. ED Patient Record Form
181864	Hospital Induction Form	Form	Modified	Hospital Induction Form
181863	Cervical Cancer Screening Supplement	Form	Modified	Att. T. Cervical Cancer Screening Supplement

ICR Details

OMB Control No: 0920-0278	ICR Reference No: 201001-0920-001
Status: Historical Active	Previous ICR Reference No: 200907-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Hospital Ambulatory Medical Care Survey
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/19/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/11/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2012	08/31/2012	08/31/2012
Responses	128,141	0	128,141
Time Burden (Hours)	10,832	0	10,832
Cost Burden (Dollars)	0	0	0

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Abstract: This request is for the revision of an approved data collection (OMB No. 0920-0278), the National Hospital Ambulatory Medical Care Survey (NHAMCS), for the purpose of collecting data for the years 2010, 2011, and 2012 and for the expanding the data collection to free-standing ambulatory surgery centers (FS-ASCs). The NHAMCS is a national survey of patient visits to emergency and outpatient departments and hospital-based ambulatory surgery centers of general and short stay hospitals. We propose to revise NHAMCS in 2010 for the purpose of collecting data from free-standing ambulatory surgery centers which formerly was collected as part of a separate approved survey, the National Survey of Ambulatory Surgery (NSAS) (OMB 0920-0334). We propose, in this package, to add the collection of data from free-standing ambulatory surgery centers to NHAMCS in 2010. In addition, this package requests approval for minor changes to the NHAMCS forms to allow for data collection from FS-ASCs and to update the forms for the emergency and outpatient departments based on past performance. We also seek approval to continue collection of the NHAMCS Cervical Cancer Screening Supplement, which has been collected since 2006.

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Authorizing Statute(s): US Code: 42 USC 306 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 6163	02/05/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 29489	06/22/2009
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
ASC Patient Record Form	unnumbered	Att. O. ASC Patient Record Form
Ambulatory Unit Record	unnumbered	Att. J. Ambulatory Unit Induction Form
Cervical Cancer Screening Supplement	unnumbered	Att. T. Cervical Cancer Screening Supplement
ED Patient Record Form	unnumbered	Att. M. ED Patient Record Form
Freestanding ASC Induction Form	none	Freestanding Ambulatory Surgery Centers Form
Hospital Induction Form	none	Hospital Induction Form
OPD Patient Record Form	unnumbered	Att. N. OPD Patient Record Form
Pulling and re-filing Patient Records

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ICR Summary of Burden

table that charts list 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	128,141	128,141	0	0	0	0
Annual Time Burden (Hours)	10,832	10,832	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $4,473,000

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)? Yes

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: 01/11/2010

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