National Hospital Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Initial Hospital Intake Questionnaire	Form	Modified	Available
Annual FSASC Interview	Form	Removed	Available
Ambulatory Unit Induction	Form	Removed	Available
0920-0212 SS A 013015.docx	Supporting Statement A	Uploaded 2015-02-19	Available
Att V - OPD PRF Changes.docx	Supplementary Document	Uploaded 2015-02-18	Available
Att U - ED PRF Changes.docx	Supplementary Document	Uploaded 2015-02-18	Available
Att T - Hosp Amb Interview Changes.docx	Supplementary Document	Uploaded 2015-02-18	Available
Att S - NHCS FAQ Brochure.pdf	Supplementary Document	Uploaded 2015-02-18	Available
Att R - OP Depart Patient Record Form.docx	Supplementary Document	Uploaded 2015-02-18	Available
Att Q - Emer Depart Patient Record Form.docx	Supplementary Document	Uploaded 2015-02-18	Available
Att M- ERB Approval Notice.pdf	Supplementary Document	Uploaded 2015-02-18	Available
Att L - Westat Data Security Plan.pdf	Supplementary Document	Uploaded 2015-02-18	Available
Att E - Amb Intro Letter to Hosp EDs OPDs.docx	Supplementary Document	Uploaded 2015-02-18	Available
Att D - Introductory Letter to Hospitals.docx	Supplementary Document	Uploaded 2015-02-18	Available
Att C - NHCS Data Collection Flow Chart.docx	Supplementary Document	Uploaded 2015-02-18	Available
Att B - Federal Register Notice for NHCS.pdf	Supplementary Document	Uploaded 2015-02-18	Available
Att A - Legislative Authority.rtf	Supplementary Document	Uploaded 2015-02-18	Available
0920-0212 SS B 013015.docx	Supporting Statement B	Uploaded 2015-02-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6666	Initial Hospital Intake Questionnaire	Form	Modified
215050	Prepare and Submit EHR for Inpatient and Ambulatory	Instruction	New
205650	FSASC Pulling and Refiling Patient Records	Instruction	Removed
205649	FSASC Prepare and Transmit UB-40	Instruction	Removed
205648	Annual FSASC Interview	Form	Removed
205647	Pulling and re-filing Patient Records (ED, OPD, and ASL)	Instruction	Removed
186285	Prepare and transmit UB-04 for Inpatient and Ambulatory	Instruction	Modified
186284	Ambulatory Unit Induction	Form	Removed
186283	Annual Ambulatory Hospital Interview	Other-Interview	Modified
186282	Annual Inpatient Hospital Interview	Other-Interview	Modified
186281	Recruitment Survey Presentation	Other-Presentation	Modified

ICR Details

OMB Control No: 0920-0212	ICR Reference No: 201502-0920-011
Status: Historical Inactive	Previous ICR Reference No: 201302-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 18672
Title: National Hospital Care Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 05/07/2015
	Date Received in OIRA: 03/03/2015
Terms of Clearance: Please resubmit with only the average annual burden that will likely be used over the three year clearance period (i.e., the revision will only allow for piloting changes in protocol and sampling, not an extension of the original clearance period.)

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2016	36 Months From Approved	04/30/2016
Responses	131,516	0	131,516
Time Burden (Hours)	7,224	0	7,224
Cost Burden (Dollars)	0	0	0

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Abstract: The National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC), requests approval to continue the National Hospital Care Survey (NHCS) (OMB No. 0920-0212) which integrates the National Hospital Ambulatory Medical Care Survey (NHAMCS) (OMB No. 0920-0278) and the Drug-Abuse Warning Network (DAWN) (OMB No. 0930-0078, expired 12/31/2011) previously conducted by the Substance Abuse and Mental Health Services Administration's (SAMHSA). Integration of NHAMCS and DAWN into the NHCS is part of a broader strategy to improve efficiency by minimizing redundancy in data collection; broadening our capability to collect more relevant data on transitions of care; and identifying opportunities to explore electronic and administrative clinical data systems to augment primary data collection.

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Authorizing Statute(s): US Code: 42 USC 242k Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 14709	03/17/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 49517	08/21/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Prepare and transmit UB-04 for Inpatient and Ambulatory
Ambulatory Unit Induction	none	Ambulatory Unit Induction
FSASC Pulling and Refiling Patient Records
FSASC Prepare and Transmit UB-40
Annual FSASC Interview	none	Annual FSASC Interview
Pulling and re-filing Patient Records (ED, OPD, and ASL)
Prepare and Submit EHR for Inpatient and Ambulatory
Annual Inpatient Hospital Interview
Annual Ambulatory Hospital Interview
Initial Hospital Intake Questionnaire	none	Initial Intake Questionnaire
Recruitment Survey Presentation

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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: Burden increased overall due to the addition of 81 hospitals to the sample. Burden decreased overall due to removal of several line items, combining of questions, new electronic capabilities and removal of 2 other functions no longer required.

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Annual Cost to Federal Government: $9,173,000

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? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 03/03/2015

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