Information Collection

NAMCS-30 Patient Record form (Line 3)

IC 181890 under ICR 201309-0920-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
NAMCS-30 Patient Record form (Line 3) Form
Patient Record Form NAMCS 2014 Attachment D 082713.docx Form
Attachment B.docx B - Changes to Patient Record Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Patient Record Form	NAMCS 2014 Attachment D 082713.docx		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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	102,210	102,210
Annual IC Time Burden (Hours)	23,849	23,849
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
B - Changes to Patient Record Form	Attachment B.docx	09/04/2013

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