Ambulatory Care Pretest: National Hospital Care Survey

Forms and Documents

Document Name	Status
Form 5 Pulling and Refiling Medical Records Form	New
Form 4 Prepare and Transmit UB-04 Files Form	New
Form 3 Ambulatory Induction Form	New
Form 2 Free-Standing Ambulatory Surgery Center Induction Form	New
Form 1 Hospital Induction Interview Form	New
Sup Sta Part B FINAL 050312.docx Supporting Statement B	2012-05-17
Att L AS PRF.docx Supplementary Document	2012-05-17
Att K OPD PRF.docx Supplementary Document	2012-05-17
Att J - NHCS Ambulatory Pretest ED PRF.xlsx Supplementary Document	2012-05-17
Att F Flowchart.docx Supplementary Document	2012-05-17
Att E FSASC Intro Letter.docx Supplementary Document	2012-05-17
Att D Hospital Intro Letter.docx Supplementary Document	2012-05-17
Att C - NHCS Ambulatory Pretest IRB Approval Letter.pdf Supplementary Document	2012-05-17
Att A Applicable Laws and Regulations.docx Supplementary Document	2012-05-17
NHCS Amb Pretest Sup Sta Part A FINAL Rev. 073012.docx Supporting Statement A	2012-07-31

IC Document Collections

IC ID	Document Title	Status
202432	Pulling and Refiling Medical Records Form	New
202431	Prepare and Transmit UB-04 Files Form	New
202430	Ambulatory Induction Form	New
202429	Free-Standing Ambulatory Surgery Center Induction Form	New
202428	Hospital Induction Interview Form	New

ICR Details

OMB Control No: 0920-0944	ICR Reference No: 201205-0920-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Ambulatory Care Pretest: National Hospital Care Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/31/2012
	Date Received in OIRA: 05/23/2012
Terms of Clearance: Request to incoroprate NAMCS and DAWN into the National Hospital Care Survey ICR must include a detailed discussion of how the design chosen was influenced by the results of the pre-test.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2013	12 Months From Approved
Responses	14,794	0	0
Time Burden (Hours)	381	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This request is for a new pretest data collection of an approved data collection (OMB No. 0920-0212, exp. 04/30/2014), the National Hospital Care Survey (NHCS), to conduct a pretest of the ambulatory component of the NHCS. Currently, the NHCS collects inpatient data from non-Federal noninstitutional hospitals with six or more beds staffed for inpatient use. Hospital ambulatory data and data from freestanding ambulatory surgery centers (FSASCs) are currently collected through the National Hospital Ambulatory Medical Care Survey (NHAMCS) (OMB No. 0920-0278, expires 12/31/2014). NHCS will also collect emergency department (ED) data previously collected through the Substance Abuse and Mental Health Services Administration's (SAMHSA) Drug Abuse Warning Network (DAWN). The proposed new pretest will test the feasibility of integrating NHAMCS and DAWN into the NHCS, as well as the collection of new data elements related to drug- and mental illness-related ED visits and colorectal cancer screening at ambulatory surgery visits. New sampling and data collection methods will be tested.

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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
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 67457	11/01/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 28597	05/15/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Hospital Induction Interview	1	Hospital Induction Form
Free-Standing Ambulatory Surgery Center Induction	2	Free-Standing Ambulatory Surgery Center Induction Form
Ambulatory Induction	3	Ambulatory Unit Induction Form
Prepare and Transmit UB-04 Files	4	Performance of Colonoscopy in the United States
Pulling and Refiling Medical Records	5	Pulling and Refiling Records

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ICR Summary 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	14,794	0	0	14,794	0	0
Annual Time Burden (Hours)	381	0	0	381	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 new ICR

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Annual Cost to Federal Government: $1,465,000

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)? No

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: 05/23/2012

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