National Hospital Ambulatory Medical Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Ambulatory Unit Induction - 5/2011	Form	Modified	Available
Att. J. Ambulatory Unit Induction Form - 11/29/2010	Form	Modified	Repair queued
Form unnumbered Att. J. Ambulatory Unit Induction Form	Form	Modified	Available
Asthma Management Supplement Pretest	Form	New	Repair queued
Freestanding Ambulatory Surgery Centers Form - pretest 5/2011	Form	Modified	Available
Freestanding Ambulatory Surgery Centers Form - 11/29/2010	Form	Modified	Available
Freestanding Ambulatory Surgery Centers Form	Form	Modified	Available
OPD Patient Record Form - 5/2011	Form	Modified	Available
OPD Patient Record - 11/29/2010	Form	Modified	Available
OPD Patient Record	Form	Modified	Available
ASC Patient Record Form - 5/2011	Form	Modified	Available
Form unnumbered Att. O. ASC Patient Record Form	Form	Modified	Available
ED Patient Record Form - 5/2011	Form	Modified	Available
Form unnumbered Att. M. ED Patient Record Form	Form	Modified	Available
Hospital Induction Form - 5/2011	Form	Modified	Available
Hospital Induction Form - 11/29/2010	Form	Modified	Available
Hospital Induction Form	Form	Modified	Repair queued
Form unnumbered Att. T. Cervical Cancer Screening Supplement	Form	Modified	Repair queued
Attachment H - NHAMCS-910 Lookback Module-revised.pdf	Supplementary Document	Uploaded 2011-05-09	Available
Attachment G - NHAMCS-100(ED)-revised.pdf	Supplementary Document	Uploaded 2011-05-09	Available
Attachment F - NHAMCS-100(ASC)-revised.pdf	Supplementary Document	Uploaded 2011-05-09	Available
Attachment E - NHAMCS-100(OPD) -rev.pdf	Supplementary Document	Uploaded 2011-05-09	Available
NHAMCS Justification for change - pretes t050211.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2011-05-09	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

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43613	Ambulatory Unit Record	Form	Modified	Ambulatory Unit Induction - 5/2011
43613	Ambulatory Unit Record	Form	Modified	Att. J. Ambulatory Unit Induction Form - 11/29/2010
43613	Ambulatory Unit Record	Form	Modified	Att. J. Ambulatory Unit Induction Form
197667	Pulling and Refiling Patient Records Pretest	Instruction	New
197666	Asthma Management Supplement	Form	New	Asthma Management Supplement Pretest
189813	Freestanding ASC Induction Form	Form	Modified	Freestanding Ambulatory Surgery Centers Form - pretest 5/2011
189813	Freestanding ASC Induction Form	Form	Modified	Freestanding Ambulatory Surgery Centers Form - 11/29/2010
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	OPD Patient Record Form - 5/2011
181867	OPD Patient Record Form	Form	Modified	OPD Patient Record - 11/29/2010
181867	OPD Patient Record Form	Form	Modified	OPD Patient Record
181866	ASC Patient Record Form	Form	Modified	ASC Patient Record Form - 5/2011
181866	ASC Patient Record Form	Form	Modified	Att. O. ASC Patient Record Form
181865	ED Patient Record Form	Form	Modified	ED Patient Record Form - 5/2011
181865	ED Patient Record Form	Form	Modified	Att. M. ED Patient Record Form
181864	Hospital Induction Form	Form	Modified	Hospital Induction Form - 5/2011
181864	Hospital Induction Form	Form	Modified	Hospital Induction Form - 11/29/2010
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: 201105-0920-007
Status: Historical Inactive	Previous ICR Reference No: 201011-0920-002
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: Withdrawn and continue	Conclusion Date: 05/26/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/11/2011
Terms of Clearance: to update

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)	12,112	0	12,112
Cost Burden (Dollars)	0	0	0

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Abstract: This request is to modify/add selected questions on Electronic medical record usage and delete the cancer supplement starting in 2011 to the ongoing OMB 0920-0278 -National Hospital Ambulatory Medical Care Survey (NHAMCS).

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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

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
ASC Patient Record Form	unnumbered, none	Att. O. ASC Patient Record Form ,   ASC Patient Record Form - 5/2011
Ambulatory Unit Record	unnumbered, none, none	Att. J. Ambulatory Unit Induction Form ,   Att. J. Ambulatory Unit Induction Form - 11/29/2010 ,   Ambulatory Unit Induction - 5/2011
Asthma Management Supplement	none	Asthma Management Supplement Pretest
Cervical Cancer Screening Supplement	unnumbered	Att. T. Cervical Cancer Screening Supplement
ED Patient Record Form	unnumbered, none	Att. M. ED Patient Record Form ,   ED Patient Record Form - 5/2011
Freestanding ASC Induction Form	none, none, none	Freestanding Ambulatory Surgery Centers Form ,   Freestanding Ambulatory Surgery Centers Form - 11/29/2010 ,   Freestanding Ambulatory Surgery Centers Form - pretest 5/2011
Hospital Induction Form	none, none, none	Hospital Induction Form ,   Hospital Induction Form - 11/29/2010 ,   Hospital Induction Form - 5/2011
OPD Patient Record Form	none, none, none	OPD Patient Record ,   OPD Patient Record - 11/29/2010 ,   OPD Patient Record Form - 5/2011
Pulling and Refiling Patient Records Pretest
Pulling and re-filing Patient Records

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 05/11/2011

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