National Ambulatory Medical Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
National Ambulatory Medical Care Survey Panel 2011	Form	Modified	Available
Att BB - NAMCS 2012 - Patient Record Form CPT Code Pretest	Form	Modified	Available
Att Z - NAMCS 2011 Panel CPT Code Pretest	Form	Modified	Available
Att O - 2012 Physician Workflow Supplelment - EHR Nonadopters	Form	Modified	Available
Att N - 2012 Physician Workflow Supplement - EHR Adopters	Form	Modified	Available
National Electronic Health Records Survey 2012	Form	Modified	Available
Att B - Asthma Supplement	Form	Modified	Available
Att E - 2012 NAMCS Lookback Module	Form	Modified	Available
Att H - NAMCS 2012 Patient Record	Form	Modified	Available
Att K - Community Health Center Induction Interview	Form	Modified	Available
Att EE 2012 NAMCS Re-abstraction Study Pulling and Re-filing.pdf	Supplementary Document	Uploaded 2011-12-12	Available
Att CC NAMCS 2012 Re-abstraction Study Patient Record Form.pdf	Supplementary Document	Uploaded 2011-12-12	Available
Copy of Attachment FF.xls	Supplementary Document	Uploaded 2011-12-12	Available
NAMCS 12-15 OMB SS-B Final-120711.doc	Supporting Statement B	Uploaded 2011-12-12	Available
Att Y NAMCS Brochure.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att X Workflow Letters.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att W Letters used in the NEHRS.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att U Advanced Letters.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att V Endorsing Agencies.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att P Federal Register.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att S ERB Letter.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att R 2011-2014 NAMCS Consultants.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att Q Federal Register Public Comments.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att A - Applicable Laws and Regulations.pdf	Supplementary Document	Uploaded 2011-11-03	Available
Att AA Changes to NAMCS-1 and NAMCS-201 Items for Survey Year 2012 CPT Code PRETEST.PDF	Supplementary Document	Uploaded 2011-11-07	Available
Att M Item modifications on the National EHR Survey 2012 from the 2011 EMRS.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att J NAMCS-1 EHR items and list of modifications.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att I Changes to the PRF from 2011 to 2012.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att D CAM definitions.pdf	Supplementary Document	Uploaded 2011-11-07	Available
Att C CAM.PDF	Supplementary Document	Uploaded 2011-11-07	Available
Att G Changes to NAMCS-1 and NAMCS-201 Items for Survey Year 2012.pdf	Supplementary Document	Uploaded 2011-11-07	Available
FINAL NAMCS 2012-2014 OMB A.docx	Supporting Statement A	Uploaded 2011-12-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43612	NAMCS-1 Physician Induction Interview (Line 1)	Form	Modified	National Ambulatory Medical Care Survey Panel 2011
196407	2012 Pretest NAMCS Patient Record Form (line 10)	Form	Modified	Att BB - NAMCS 2012 - Patient Record Form CPT Code Pretest
196406	2012 CPT Pretest NAMCS-1 (line 9)	Form	Modified	Att Z - NAMCS 2011 Panel CPT Code Pretest
196405	Physician Workflow Survey (line 8)	Form	Modified	Att O - 2012 Physician Workflow Supplelment - EHR Nonadopters
196405	Physician Workflow Survey (line 8)	Form	Modified	Att N - 2012 Physician Workflow Supplement - EHR Adopters
196404	National Electronic Health Records Survey (line 7)	Form	Modified	National Electronic Health Records Survey 2012
196403	2012 Asthma Supplement (line 6)	Form	Modified	Att B - Asthma Supplement
189597	Lookback Module (Line 5)	Form	Modified	Att E - 2012 NAMCS Lookback Module
181891	Pulling and re-filing Patient Record form (Line 4)	Instruction	Modified
181890	NAMCS-30 Patient Record form (Line 3)	Form	Modified	Att H - NAMCS 2012 Patient Record
181889	NAMCS-201 Community Health Center Induction Interview (Line 2)	Form	Modified	Att K - Community Health Center Induction Interview

ICR Details

OMB Control No: 0920-0234	ICR Reference No: 201111-0920-001
Status: Historical Active	Previous ICR Reference No: 201102-0920-016
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Ambulatory Medical Care Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/13/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/08/2011
Terms of Clearance: New modules must be submitted to OMB for approval as substantive changes.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved	03/31/2013
Responses	528,615	0	71,827
Time Burden (Hours)	46,622	0	11,502
Cost Burden (Dollars)	0	0	0

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Abstract: Data collected from office-based physicians, and community health center providers, concerning patient visits are aggregated to national statistics. Changes are requested for 2012-2014 survey period, including 1) increase sample size to 34 states, 2) modify sampling design from geographic primary sampling unit to list based sample, 3) implement automation of data collection, 4) field new survey components and 5) conduct a pretest in Spring 2012 to evaluate ability to collect current procedural terminology codes. Other survey activities will continue with minor item modifications.

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Authorizing Statute(s): US Code: 42 USC 242K Name of Law: Public Health Service Act
   PL: Pub.L. 111 - 5 1512 Name of Law: American Recovery and Reinvestment Act of 2009
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 39947	10/13/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 68464	11/04/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
2012 Asthma Supplement (line 6)	none	Att B - Asthma Supplement
2012 CPT Pretest NAMCS-1 (line 9)	none	Att Z - NAMCS 2011 Panel CPT Code Pretest
2012 Pretest NAMCS Patient Record Form (line 10)	none	Att BB - NAMCS 2012 - Patient Record Form CPT Code Pretest
Lookback Module (Line 5)	none	Att E - 2012 NAMCS Lookback Module
NAMCS-1 Physician Induction Interview (Line 1)	none	National Ambulatory Medical Care Survey Panel 2011
NAMCS-201 Community Health Center Induction Interview (Line 2)	none	Att K - Community Health Center Induction Interview
NAMCS-30 Patient Record form (Line 3)	none	Att H - NAMCS 2012 Patient Record
National Electronic Health Records Survey (line 7)	none	National Electronic Health Records Survey 2012
Physician Workflow Survey (line 8)	none, none	Att N - 2012 Physician Workflow Supplement - EHR Adopters ,   Att O - 2012 Physician Workflow Supplelment - EHR Nonadopters
Pulling and re-filing Patient Record form (Line 4)

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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	528,615	71,827	0	456,788	0	0
Annual Time Burden (Hours)	46,622	11,502	0	35,120	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The estimated annualized burden hours are higher because there are more planned activities for the 2012-2014 survey period.

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Annual Cost to Federal Government: $11,399,149

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]? Yes

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: 11/08/2011

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