Information Collection

Pretests

IC 197941 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⚠️ Notice: This information collection may be referencing outdated material.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
Pretests	Form
Ambulatory Unit Induction pretest Attachment C - NHAMCS-101(U).pdf	Form
Freestanding Ambulatory Surgery Center Induction pretest Attachment B - NHAMCS-101FS.pdf	Form
Asthma Management Supplement pretest Attachment D - NHAMCS-908 Asthma Supplement-revised.pdf	Form
Hospital Induction pretest Attachment A - NHAMCS-101.pdf	Form
Outpatient Dept Patient Record pretest Attachment E - NHAMCS-100(OPD) -rev.pdf	Form
Ambulatory Surgery Center Patient Record pretest Attachment F - NHAMCS-100(ASC)-revised.pdf	Form
Emergency Dept Patient Record pretest Attachment G - NHAMCS-100(ED)-revised.pdf	Form
Lookback Module pretest Attachment H - NHAMCS-910 Lookback Module-revised.pdf	Form
Pulling and Refiling Records pretest Attachment I - Pulling records.doc	Form

IC Title:

Pretests

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	Outpatient Dept Patient Record pretest	Attachment E - NHAMCS-100(OPD) -rev.pdf	No	No	Paper Only
Form	none	Ambulatory Surgery Center Patient Record pretest	Attachment F - NHAMCS-100(ASC)-revised.pdf	No	No	Paper Only
Form	none	Emergency Dept Patient Record pretest	Attachment G - NHAMCS-100(ED)-revised.pdf	No	No	Paper Only
Form	none	Lookback Module pretest	Attachment H - NHAMCS-910 Lookback Module-revised.pdf	No	No	Paper Only
Form	none	Pulling and Refiling Records pretest	Attachment I - Pulling records.doc	No	No	Paper Only
Form	none	Ambulatory Unit Induction pretest	Attachment C - NHAMCS-101(U).pdf	No	No	Paper Only
Form	none	Freestanding Ambulatory Surgery Center Induction pretest	Attachment B - NHAMCS-101FS.pdf	No	No	Paper Only
Form	none	Asthma Management Supplement pretest	Attachment D - NHAMCS-908 Asthma Supplement-revised.pdf	No	No	Paper Only
Form	none	Hospital Induction pretest	Attachment A - NHAMCS-101.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 120

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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,028	1,028
Annual IC Time Burden (Hours)	82	82
Annual IC Cost Burden (Dollars)	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.