NAMCS-30 Patient Record form (Line 3)

National Ambulatory Medical Care Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Document Name Document Type
NAMCS-30 Patient Record form (Line 3) Form
NAMCS 2011 Patient Record Folio Att G FINAL namcs30.pdf Form

Information Collection (IC) Details

IC Title:	NAMCS-30 Patient Record form (Line 3)	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	NAMCS 2011 Patient Record Folio	Att G FINAL namcs30.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: 1,017	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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	30,510	8,370	22,140
Annual IC Time Burden (Hours)	5,594	2,273	3,321
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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