ASC Patient Record Form

National Hospital Ambulatory Medical Care Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0278 can be found here:

Documents and Forms

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

Information Collection (IC) Details

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:

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: 54	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,400	-15,400	20,800
Annual IC Time Burden (Hours)	630	-1,450	2,080
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.