Information Collection

ED Patient Record Form

IC 181865 under ICR 201106-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form unnumbered ED Patient Record Form	Form
unnumbered Att. M. ED Patient Record Form NHAMCS2010 Attachment M - NHAMCS-100(ED).pdf	Form
NHAMCS2010 Attachment Q - NHAMCS-122.pdf Att. Q. Emergency Dept. Instructions	IC Document

IC Title:

ED Patient Record 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	unnumbered	Att. M. ED Patient Record Form	NHAMCS2010 Attachment M - NHAMCS-100(ED).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: 225

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	22,500	22,500
Annual IC Time Burden (Hours)	2,625	2,625
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att. Q. Emergency Dept. Instructions	NHAMCS2010 Attachment Q - NHAMCS-122.pdf	06/08/2009

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