Information Collection

NAMCS-30 Patient Record form (Line 3)

IC 181890 under ICR 201211-0920-001 · OMB 0920-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
NAMCS-30 Patient Record form (Line 3)	Form
National Ambulatory Medical Care Survey 2013 Medical Rec Attachment B.pdf	Form
Att I Changes to the PRF from 2011 to 2012.pdf Att I - Patient Record Form changes	IC Document
Att CC NAMCS 2012 Re-abstraction Study Patient Record Form.pdf Att CC NAMCS 2012 Re-abstraction Study Patient Record Form	IC Document

IC Title:

NAMCS-30 Patient Record form (Line 3)

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	None	National Ambulatory Medical Care Survey 2013 Medical Record Form	Attachment B.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 3,407

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	102,210	4,770	97,440
Annual IC Time Burden (Hours)	23,849	1,113	22,736
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att I - Patient Record Form changes	Att I Changes to the PRF from 2011 to 2012.pdf	11/07/2011
Att CC NAMCS 2012 Re-abstraction Study Patient Record Form	Att CC NAMCS 2012 Re-abstraction Study Patient Record Form.pdf	12/12/2011

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