Information Collection

ASL Patient Record Form

IC 181866 under ICR 201412-0920-013 · OMB 0920-0278.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0278 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ASL Patient Record Form	Form
Ambulatory Surgery Attachment H - 2014 Ambulatory Surgery PRF Screenshots 103013.docx	Form

IC Title:

ASL Patient Record Form

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	Ambulatory Surgery	Attachment H - 2014 Ambulatory Surgery PRF Screenshots 103013.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utlization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-5,400	5,400
Annual IC Time Burden (Hours)	-630	630
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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