Att O - NAMCS Control Card Panel

Attachment O: National Ambulatory Medical Care Survey Control Card 2011 Panel
OMB No. 0920-0234 Exp. Date 02/28/2013

ADDRESS AND TELEPHONE INFORMATION
1. Physician’s Address

Assurance of confidentiality – All information which would
permit identification of an individual, a practice, or an establishment will
be held confidential; will be used only for statistical purposes only by
NCHS staff, contractors, and agents only when required and with
necessary controls; and will not be disclosed or released to other
persons without the consent of the individual or the establishment in
accordance with section 308(d) of the Public Health Service Act (42
USC 242m) and the Confidential Information Protection and Statistical
Efficiency Act (PL-107-347).

NAMCS-1(CC)

FORM
(11-16-2010)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Health Statistics

NATIONAL AMBULATORY
MEDICAL CARE SURVEY
CONTROL CARD
2011 PANEL
2. Physician’s telephone and FAX numbers (Area code and number)
Telephone

Telephone

Office 1

Office 2
FAX

FAX

4. Record of telephone calls
Call

Date

Time

Results

1
2
3
4
5
6
7
10b. What is the (correct) address and telephone number of your office?
Correct
Number and street
Address
and
Telephone City
number

State

Telephone number (Area code and number)

12. Verify office location, if appropriate:

CONTINUE ON REVERSE

ZIP Code

Section II – INDUCTION INTERVIEW
16a. Office location(s)
At what office location(s) will you see
ambulatory patients during your
practice’s 7-day reporting period

Office
number

Office Location
(Enter street address)
Same office designated in the Control Card, Item 1 Address Label.

Monday, ____________ through
Sunday, ____________ ?

1
2
3
4

17a. Enter the street name or town of in-scope location(s).
Note: Keep the location numbers the same as the office number in item 16a.
Office No. 1
Office No. 3

Office No. 2

Office No. 4

18h. What is your Federal Tax ID at each office location?
Office No. 1

Office No. 3

Office No. 2

Office No. 4

33b. Who will be helping you at each location?
Below enter the location and person’s name and position.
Note – Keep the location numbers the same as the office numbers in item 16a.
Office
Number

Location (Enter street name)

Name

Position

1
2
3
4
Section III – NONINTERVIEW
39a. What is the
provider’s new
address?

Number and Street
City

State

ZIP Code

Telephone number (Area code and number)
39b. Name of Field
Representative

RO

PSU

Date transferred

CONTINUE WITH ITEM 40 ON PAGE 21 OR THE NAMCS-1
FORM NAMCS-1(CC) (11-16-2010)