NAMCS-30 Patient Record Form

National Ambulatory Medical Care Survey

⚠️ Notice: This information collection may be referencing outdated material.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 Form
NAMCS-30 Form Att D1 - 2014 NAMCS-73 PRF.pdf Form
NAMCS-30 Card Att D2 - 2015 NAMCS-73 PRF.docx Form
Att D3 - 2015 NAMCS-73 PRF Changes.docx NAMCS-30 Table of Proposed Changes IC Document

Information Collection (IC) Details

IC Title:	NAMCS-30 Patient Record 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	none	NAMCS-30 Form	Att D1 - 2014 NAMCS-73 PRF.pdf		Yes	Yes	Fillable Fileable
Form	none	NAMCS-30 Card	Att D2 - 2015 NAMCS-73 PRF.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20--0167 Health Resources Utilization Statistics	FR Citation: 49 FR 37693

Number of Respondents: 1,932	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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	57,960	57,960
Annual IC Time Burden (Hours)	13,524	13,524
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
NAMCS-30 Table of Proposed Changes	Att D3 - 2015 NAMCS-73 PRF Changes.docx	11/13/2014

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