Information Collection

Freestanding ASC Induction Form

IC 189813 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Freestanding ASC Induction Form	Form
Freestanding Ambulatory Surgery Centers Form Attachment B - 2010 NHAMCS-101(FS).pdf	Form
Freestanding Ambulatory Surgery Centers Form - 11/29/201 nhamcs101fs.pdf	Form
Freestanding Ambulatory Surgery Centers Form - pretest 5 Attachment B - NHAMCS-101FS.pdf	Form

IC Title:

Freestanding ASC Induction Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Freestanding Ambulatory Surgery Centers Form	Attachment B - 2010 NHAMCS-101(FS).pdf	Yes	No	Paper Only
Form	none	Freestanding Ambulatory Surgery Centers Form - 11/29/2010	nhamcs101fs.pdf	Yes	No	Paper Only
Form	none	Freestanding Ambulatory Surgery Centers Form - pretest 5/2011	Attachment B - NHAMCS-101FS.pdf	Yes	No	Fillable Fileable

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: 208

Number of Respondents for Small Entity: 25

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	208	8	200
Annual IC Time Burden (Hours)	312	12	300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.