Information Collection

NAMCS-30 Patient Record form (Line 3)

IC 181890 under ICR 201411-0920-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

IC Title:

NAMCS-30 Patient Record form (Line 3)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	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 %

table that charts list of burden
	Program Change Due to Agency Discretion	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

table that charts IC Documents
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.