Information Collection

Hospital Induction Form

IC 181864 under ICR 201105-0920-007 · OMB 0920-0278.

⚠️ Notice: This information collection may be referencing outdated material.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
Hospital Induction Form - 11/29/2010 nhamcs101.pdf Form
Hospital Induction Form - 5/2011 Attachment A - NHAMCS-101.pdf Form
NHAMCS2010 Attachment K - NHAMCS-103.pdf Att. K. Patient Visit Log IC Document

Information Collection (IC) Details

View Information Collection (IC)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Hospital Induction Form	Attachment A - 2010 NHAMCS-101.pdf	Yes	Yes	Paper Only
Form	none	Hospital Induction Form - 11/29/2010	nhamcs101.pdf	Yes	Yes	Paper Only
Form	none	Hospital Induction Form - 5/2011	Attachment A - 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: 494	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	494	12	482
Annual IC Time Burden (Hours)	494	12	482
Annual IC Cost Burden (Dollars)	0	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.