Information Collection

ASC Patient Record Form

IC 181866 under ICR 201110-0920-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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 ASC Patient Record Form	Form
unnumbered Att. O. ASC Patient Record Form NHAMCS2010 Attachment O - NHAMCS-100(ASC).pdf	Form
NHAMCS2010 Attachment S - NHAMCS-126.pdf Att. S. ASC Instruction Booklet	IC Document

IC Title:

ASC 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. O. ASC Patient Record Form	NHAMCS2010 Attachment O - NHAMCS-100(ASC).pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utlization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 208

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	20,800	20,800
Annual IC Time Burden (Hours)	2,080	2,080
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att. S. ASC Instruction Booklet	NHAMCS2010 Attachment S - NHAMCS-126.pdf	06/08/2009

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