Information Collection

Electronic Medical Record/Electronic Health Record Mail Survey Form

IC 189598 under ICR 201002-0920-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form unnumbered Electronic Medical Record/Electronic Health Record Mail Survey Form	Form
unnumbered EMR/EHR Mail Survey form NAMCS 09-12 OMB ATT T.pdf	Form
NAMCS 09-12 OMB ATT S.pdf EMR/EHR letters and script	IC Document

IC Title:

Electronic Medical Record/Electronic Health Record Mail Survey Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	unnumbered	EMR/EHR Mail Survey form	NAMCS 09-12 OMB ATT T.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 1,143

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 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-1,143	1,143
Annual IC Time Burden (Hours)	-381	381
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
EMR/EHR letters and script	NAMCS 09-12 OMB ATT S.pdf	05/11/2009

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