Hospital Data Abstraction Form

Evaluation of Emergency Department Crisis Center Follow-up

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0337 can be found here:

Documents and Forms

Document Name Document Type
Form Hospital Data Abst Hospital Data Abstraction Form Form and Instruction
Hospital Data Abst Hospital Data Abstraction Form Attachment A_Hospital Data Abstraction Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Hospital Data Abstraction Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	Hospital Data Abstraction Form	Hospital Data Abstraction Form	Attachment A_Hospital Data Abstraction Form.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	667	667
Annual IC Time Burden (Hours)	27	27
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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