ASL Patient Record Form

National Hospital Ambulatory Medical Care Survey

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
ASL Patient Record Form Form
Ambulatory Surgery Attachment H - 2014 Ambulatory Surgery PRF Screenshots 103013.docx Form

Information Collection (IC) Details

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:

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 %

	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

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.