Information Collection

NAMCS-30 Patient Record Form

IC 213882 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⚠️ Notice: This information collection may be referencing outdated material.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	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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.