Information Collection

Lookback Module (Line 5)

IC 189597 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⚠️ Notice: This information collection may be referencing outdated material.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
Lookback Module (Line 5)	Form
National Ambulatory Medical Care Survey 2013 Look Back M Attachment C.pdf	Form
Att DD 2012 NAMCS Re-abstraction Study Lookback Module.pdf Att DD 2012 NAMCS Re-abstraction Study Lookback Module	IC Document

IC Title:

Lookback Module (Line 5)

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 Look Back Module	Attachment C.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization

FR Citation: 49 FR 37693

Number of Respondents: 1,192

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	17,880	12,197	5,683
Annual IC Time Burden (Hours)	2,980	2,033	947
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att DD 2012 NAMCS Re-abstraction Study Lookback Module	Att DD 2012 NAMCS Re-abstraction Study Lookback Module.pdf	12/12/2011

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