National Hospital Ambulatory Medical Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Att. J. Ambulatory Unit Induction Form - 11/29/2010	Form	Modified	Available
Form unnumbered Att. J. Ambulatory Unit Induction Form	Form	Modified	Available
Pulling & Refiling Records Pretest	Form	New	Available
Lookback Module Pretest	Form	New	Available
Emergency Dept Patient Pretest	Form	New	Available
Ambulatory Surgery Center Pretest	Form	New	Available
Outpatient Dept Patient Record Pretest	Form	New	Available
Asthma Management Supplement Pretest	Form	New	Available
Freestanding Ambulatory Surgery Center Induction	Form	New	Available
Ambulatory Unit Induction pretest	Form	New	Available
Hospital Induction Pretest	Form	New	Repair queued
Freestanding Ambulatory Surgery Centers Form - 11/29/2010	Form	Modified	Available
Freestanding Ambulatory Surgery Centers Form	Form	Modified	Available
OPD Patient Record - 11/29/2010	Form	Modified	Available
OPD Patient Record	Form	Modified	Available
Form unnumbered Att. O. ASC Patient Record Form	Form	Modified	Available
Form unnumbered Att. M. ED Patient Record Form	Form	Modified	Available
Hospital Induction Form - 11/29/2010	Form	Modified	Available
Hospital Induction Form	Form	Modified	Available
Form unnumbered Att. T. Cervical Cancer Screening Supplement	Form	Modified	Available
NHAMCS_Justification_for_change_-_pretes_t0502111 rev 052611.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2011-06-08	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	Att. J. Ambulatory Unit Induction Form - 11/29/2010
43613	Ambulatory Unit Record	Form	Modified	Att. J. Ambulatory Unit Induction Form
198054	Pretests	Form	New	Pulling & Refiling Records Pretest
198054	Pretests	Form	New	Lookback Module Pretest
198054	Pretests	Form	New	Emergency Dept Patient Pretest
198054	Pretests	Form	New	Ambulatory Surgery Center Pretest
198054	Pretests	Form	New	Outpatient Dept Patient Record Pretest
198054	Pretests	Form	New	Asthma Management Supplement Pretest
198054	Pretests	Form	New	Freestanding Ambulatory Surgery Center Induction
198054	Pretests	Form	New	Ambulatory Unit Induction pretest
198054	Pretests	Form	New	Hospital Induction Pretest
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 - 11/29/2010
181867	OPD Patient Record Form	Form	Modified	OPD Patient Record
181866	ASC Patient Record Form	Form	Modified	Att. O. ASC Patient Record Form
181865	ED Patient Record Form	Form	Modified	Att. M. ED Patient Record Form
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: 201106-0920-008
Status: Historical Active	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: Approved without change	Conclusion Date: 06/10/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/10/2011
Terms of Clearance:

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	128,161	0	128,141
Time Burden (Hours)	12,194	0	12,112
Cost Burden (Dollars)	0	0	0

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Abstract: This request is to contuct pretests for the automation of the 2012 National Hospital Ambulatory Medical Care Survey (NHAMCS), and to test an asthma supplement.

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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: 9

table that charts list of burden

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

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	128,161	128,141	0	20	0	0
Annual Time Burden (Hours)	12,194	12,112	0	82	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: This is a pretest of a different mode of administration for the forms already that were already approved

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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: 06/10/2011

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