Hospital Induction Form

National Hospital Ambulatory Medical Care Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0278 can be found here:

Documents and Forms

Document Name Document Type
Hospital Induction Form Form
Hospital Induction Form Attachment A - 2010 NHAMCS-101.pdf Form
NHAMCS2010 Attachment K - NHAMCS-103.pdf Att. K. Patient Visit Log IC Document

Information Collection (IC) Details

IC Title:	Hospital Induction Form	Agency IC Tracking Number:

Is this a Common Form? No		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
Form	none	Hospital Induction Form	Attachment A - 2010 NHAMCS-101.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health Resources Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 482	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	482	482
Annual IC Time Burden (Hours)	482	482
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att. K. Patient Visit Log	NHAMCS2010 Attachment K - NHAMCS-103.pdf	06/08/2009

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