Initial Hospital Intake Questionnaire

National Hospital Care Survey

OMB: 0920-0212

IC ID: 6666

Information Collection (IC) Details

View Information Collection (IC)

Initial Hospital Intake Questionnaire
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form none Initial Hospital Intake Attachment I- Initial Intake Questionnaire.docx Yes Yes Fillable Fileable

Health Immunization Management

09-20-0167 Health Resources Utilization Statistics  49 FR 37697

133 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 133 0 100 0 0 33
Annual IC Time Burden (Hours) 133 0 125 0 0 8
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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