Form 5 Pulling and Refiling Records

ATTACHMENT M

Pulling and Refiling Records

Ambulatory Care Pretest: National Hospital Care Survey

OMB No. 0920-xxxx

Exp. Date: ________

Assurance of confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and

with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the

Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Notice – Public reporting burden for this collection of information is estimated to average

1 minute per response, including time for reviewing instructions, searching existing data

sources, gathering and maintaining the data needed, and completing and reviewing the

collection of information. An agency may not conduct or sponsor, and a person is not

required to respond to, a collection of information unless it displays a current valid OMB

control number. Send comments regarding this burden estimate or any other aspect of

this collection of information, including suggestions for reducing burden to: CDC/ATSDR

Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333,

ATTN: PRA (0920-xxxx).

We estimate that approximately 140 ambulatory units participating in NHCS ambulatory pretest, will allow the contractor’s field managers to complete the Patient Record forms. The average burden for these respondents is one minute for each form, which includes simply pulling and re-filing the medical records. Each ambulatory unit submits forms on an average of 104 patients, which makes the total burden for each ambulatory unit approximately 1 hour and 44 minutes.