Information Collection Request

National Hospital Ambulatory Medical Care Survey

ICR 201110-0920-011 · OMB 0920-0278 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Lookback Module Pretest Form Modified Available
Emergency Dept Patient Pretest Form Modified Available
Ambulatory Surgery Center Pretest Form Modified Available
Outpatient Dept Patient Record Pretest Form Modified Available
Asthma Management Supplement Pretest Form Modified Available
Freestanding Ambulatory Surgery Center Induction Form Modified Available
Ambulatory Unit Induction pretest Form Modified Available
Hospital Induction Pretest Form Modified Repair queued
Pulling & Refiling Records Pretest Form Modified Available
Form unnumbered Att. O. ASC Patient Record Form Form Modified Available
Form unnumbered Att. T. Cervical Cancer Screening Supplement Form Modified Available
Revised NHAMCS 2012-2014 Supporting Stat B OMB FINAL 12022011.docx Supporting Statement B Uploaded 2011-12-02 Available
Attachment Q - Colonoscopy Supplement Pilot Questions.docx Supplementary Document Uploaded 2011-10-20 Available
Attachment H - Endorsing Letters.doc Supplementary Document Uploaded 2011-10-20 Available
Attachment G - Introductory Letters.doc Supplementary Document Uploaded 2011-10-20 Available
Attachment F - CDC #2010-03 IRB Approval for Continuation of Protocol.docx Supplementary Document Uploaded 2011-10-20 Available
Attachment E - List of Consultants.doc Supplementary Document Uploaded 2011-10-20 Available
Attachment D - Public Comment on 60 Day Notice.docx Supplementary Document Uploaded 2011-10-20 Available
Attachment B - List of Publications.docx Supplementary Document Uploaded 2011-10-20 Available
NHAMCS2010 Attachment S - NHAMCS-126.pdf Supplementary Document Uploaded 2009-06-08 Available
Revised NHAMCS 2012-2014 Supporting Stat A OMB FINAL 12022011.docx Supporting Statement A Uploaded 2011-12-02 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
43613 Ambulatory Unit Induction Instruction Modified
199913 Hospital Induction (new sample) Instruction New
198054 Pretests Form ModifiedLookback Module Pretest
198054 Pretests Form ModifiedEmergency Dept Patient Pretest
198054 Pretests Form ModifiedAmbulatory Surgery Center Pretest
198054 Pretests Form ModifiedOutpatient Dept Patient Record Pretest
198054 Pretests Form ModifiedAsthma Management Supplement Pretest
198054 Pretests Form ModifiedFreestanding Ambulatory Surgery Center Induction
198054 Pretests Form ModifiedAmbulatory Unit Induction pretest
198054 Pretests Form ModifiedHospital Induction Pretest
198054 Pretests Form ModifiedPulling & Refiling Records Pretest
189813 Freestanding ASC Induction Form Instruction Modified
181868 Pulling and re-filing Patient Records Instruction Modified
181867 OPD Patient Record Form Instruction Modified
181866 ASC Patient Record Form Form ModifiedAtt. O. ASC Patient Record Form
181865 ED Patient Record Form Instruction Modified
181864 Hospital Induction Form Instruction Modified
181863 Cervical Cancer Screening Supplement Form ModifiedAtt. T. Cervical Cancer Screening Supplement

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
12/31/2014 36 Months From Approved 08/31/2012
111,395 0 128,161
9,999 0 12,194
0 0 0





Reginfo record details
10
table that charts list of burden
IC Title Form No. Form Name
ASC Patient Record Form unnumbered
Ambulatory Unit Induction
Cervical Cancer Screening Supplement unnumbered
ED Patient Record Form
Freestanding ASC Induction Form
Hospital Induction (new sample)
Hospital Induction Form
OPD Patient Record Form
Pretests none, none, none, none, none, none, none, none, none ,   ,   ,   ,   ,   ,   ,   ,  
Pulling and re-filing Patient Records

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 111,395 128,161 0 -16,766 0 0
Annual Time Burden (Hours) 9,999 12,194 0 -2,195 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No