National Hospital Ambulatory Medical Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
NHAMCS Ambulatory Surgery Center Patient Record Form	Form and Instruction	New	Available
NHAMCS Outpatient Department Patient Record Form	Form and Instruction	New	Available
NHAMCS Emergency Department Patient Record Form	Form and Instruction	New	Available
NHAMCS Ambulatory Unit Induction Form	Form and Instruction	New	Available
NHAMCS Hospital Induction Form	Form and Instruction	New	Available
OPD Screenshots	Form	Removed	Available
Ambulatory Surgery	Form	Removed	Available
ED Screenshots	Form	Removed	Available
Hospital Induction Interview	Form	Removed	Available
NHAMCS 2015-2017 Supporting Stat B FINAL.docx	Supporting Statement B	Uploaded 2014-12-18	Available
NHAMCS 2015-2017 Supporting Stat A FINAL.docx	Supporting Statement A	Uploaded 2014-12-18	Available
Attachment O - ASL PRF Changes 2015.docx	Supplementary Document	Uploaded 2014-12-17	Available
Attachment N - OPD PRF Changes 2015.docx	Supplementary Document	Uploaded 2014-12-17	Available
Attachment M - ED PRF Changes 2015.docx	Supplementary Document	Uploaded 2014-12-17	Available
Attachment H.2 - NHAMCS EHR Changes.docx	Supplementary Document	Uploaded 2014-12-17	Available
Attachment G - Endorsing Letters.doc	Supplementary Document	Uploaded 2014-12-17	Available
Attachment F - Introductory Letter.doc	Supplementary Document	Uploaded 2014-12-17	Available
Attachment E - CDC #2010-03 IRB Approval for Continuation of Protocol.pdf	Supplementary Document	Uploaded 2014-12-17	Available
Attachment D - List of Consultants.docx	Supplementary Document	Uploaded 2014-12-17	Available
Attachment C - Federal Register 60-Day Notice and Public Comment.pdf	Supplementary Document	Uploaded 2014-12-17	Available
Attachment B - List of publications .docx	Supplementary Document	Uploaded 2014-12-17	Available
Attachment A - Applicable Laws and Regulations.doc	Supplementary Document	Uploaded 2014-12-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43613	Ambulatory Unit Induction	Instruction	Removed
214307	Retrieve Medical Records Records (Reabstraction)	Instruction	New
214306	Reabstraction Telephone Call	Instruction	New
214305	Retrieve Medical Records	Instruction	New
214304	Ambulatory Surgery Center Patient Record Form	Form and Instruction	New	NHAMCS Ambulatory Surgery Center Patient Record Form
214303	Outpatient Department Patient Record Form	Form and Instruction	New	NHAMCS Outpatient Department Patient Record Form
214302	Emergency Department Patient Record Form	Form and Instruction	New	NHAMCS Emergency Department Patient Record Form
214300	Ambulatory Unit Induction Interview	Form and Instruction	New	NHAMCS Ambulatory Unit Induction Form
214297	Hospital Induction Interview	Form and Instruction	New	NHAMCS Hospital Induction Form
201697	Medical Record Reabstraction	Instruction	Removed
201696	Reabstraction Telephone Call	Instruction	Removed
181868	Pulling and re-filing Patient Records	Instruction	Removed
181867	OPD Patient Record Form	Form	Removed	OPD Screenshots
181866	ASL Patient Record Form	Form	Removed	Ambulatory Surgery
181865	ED Patient Record Form	Form	Removed	ED Screenshots
181864	Hospital Induction Form	Form	Removed	Hospital Induction Interview

ICR Details

OMB Control No: 0920-0278	ICR Reference No: 201412-0920-013
Status: Historical Active	Previous ICR Reference No: 201311-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No: 20786
Title: National Hospital Ambulatory Medical Care Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/06/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/29/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2018	36 Months From Approved	02/28/2015
Responses	105,768	0	132,443
Time Burden (Hours)	4,412	0	7,352
Cost Burden (Dollars)	0	0	0

---

Abstract: This request is for the revision of an approved data collection (OMB No. 0920-0278), the National Hospital Ambulatory Medical Care Survey (NHAMCS). NCHS requests to continue the survey activities for NHAMCS for 3 years and slightly modify survey activities. NHAMCS is a national survey of patient visits to emergency departments, outpatient departments, and ambulatory surgery locations of general and short-stay hospitals. The revisions included in this request entail making slight modifications to NHAMCS questions.

---

Authorizing Statute(s): US Code: 42 USC 306 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 49520	08/21/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 77495	12/24/2014
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
ASL Patient Record Form	none	Ambulatory Surgery
Ambulatory Surgery Center Patient Record Form	None	NHAMCS Ambulatory Surgery Center Patient Record Form
Ambulatory Unit Induction
Ambulatory Unit Induction Interview	None	NHAMCS Ambulatory Unit Induction Form
ED Patient Record Form	none	ED Screenshots
Emergency Department Patient Record Form	None	NHAMCS Emergency Department Patient Record Form
Hospital Induction Form	none	Hospital Induction Interview
Hospital Induction Interview	None	NHAMCS Hospital Induction Form
Medical Record Reabstraction
OPD Patient Record Form	none	OPD Screenshots
Outpatient Department Patient Record Form	None	NHAMCS Outpatient Department Patient Record Form
Pulling and re-filing Patient Records
Reabstraction Telephone Call
Reabstraction Telephone Call
Retrieve Medical Records
Retrieve Medical Records Records (Reabstraction)

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	105,768	132,443	0	-24,896	-1,779	0
Annual Time Burden (Hours)	4,412	7,352	0	-2,495	-445	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Reduction in Burden Hours in this ICR Revision is due to changes to surveys associated with the ICR as well as increased use of Field Representative abstraction of records.

---

Annual Cost to Federal Government: $6,289,206

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/29/2014

---