National Hospital Ambulatory Medical Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0278 2016 Ambulatory Surgery Center Patient Record Form	Form and Instruction	Modified	Available
Form 0920-0278 2016 Outpatient Department Patient Record Form	Form and Instruction	Modified	Available
Form 0920-0278 2016 Emergency Department Patient Record Form	Form and Instruction	Modified	Available
Ambulatory Unit Induction Interview	Form and Instruction	Unchanged	Available
Form 0920-0278 Hospital Induction Interview	Form and Instruction	Modified	Available
NHAMCS 2016 nonsub supp statement 101615.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2015-10-28	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	Repair queued
Attachment E - CDC #2010-03 IRB Approval for Continuation of Protocol.pdf	Supplementary Document	Uploaded 2014-12-17	Repair queued
Attachment D - List of Consultants.docx	Supplementary Document	Uploaded 2014-12-17	Repair queued
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	Repair queued
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
214307	Retrieve Medical Records Records (Reabstraction)	Instruction	Unchanged
214306	Reabstraction Telephone Call	Instruction	Unchanged
214305	Retrieve Medical Records	Instruction	Unchanged
214304	2016 Ambulatory Surgery Center Patient Record Form	Form and Instruction	Modified
214303	2016 Outpatient Department Patient Record Form	Form and Instruction	Modified
214302	2016 Emergency Department Patient Record Form	Form and Instruction	Modified
214300	Ambulatory Unit Induction Interview	Form and Instruction	Unchanged
214297	Hospital Induction Interview	Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0278	ICR Reference No: 201510-0920-005
Status: Historical Active	Previous ICR Reference No: 201412-0920-013
Agency/Subagency: HHS/CDC	Agency Tracking No: 20786
Title: National Hospital Ambulatory Medical Care Survey
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/23/2015
	Date Received in OIRA: 11/02/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2018	02/28/2018	02/28/2018
Responses	105,768	0	105,768
Time Burden (Hours)	4,298	0	4,412
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): US Code: 42 USC 306 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:
	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

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

table that charts list of burden

IC Title	Form No.	Form Name
2016 Ambulatory Surgery Center Patient Record Form	0920-0278	Attachment D - 2016 NHAMCS ASL PRF Changes
Reabstraction Telephone Call
Retrieve Medical Records Records (Reabstraction)
Hospital Induction Interview	0920-0278	Attachment A - 2016 NHAMCS Hospital Induction Questionnaire - Electronic Health Record Question Changes
Retrieve Medical Records
Ambulatory Unit Induction Interview	None	NHAMCS Ambulatory Unit Induction Form
2016 Emergency Department Patient Record Form	0920-0278	Attachment B - 2016 NHAMCS ED PRF Changes
2016 Outpatient Department Patient Record Form	0920-0278	Attachment C - 2016 NHAMCS OPD PRF Changes

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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	105,768	0	0	0	0
Annual Time Burden (Hours)	4,298	4,412	0	-114	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The currently approved burden for this NHAMCS package is 4,412 hours. The proposed changes to the 2016 survey, particularly the modification of the Electronic Health Records (EHR) questions captured in the Hospital Induction instrument, will reduce the burden to the respondent by 114 hours, resulting in a final burden of 4,298 hours.

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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

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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: 11/02/2015

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