2016 Emergency Department 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0278 2016 Emergency Department Patient Record Form Form and Instruction
Attachment F - 2016 NHAMCS ED PRF Sample Card.pdf Instruction
0920-0278 Attachment B - 2016 NHAMCS ED PRF Changes Attachment B - 2016 NHAMCS ED PRF Changes.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	2016 Emergency Department Patient Record Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 and Instruction	0920-0278	Attachment B - 2016 NHAMCS ED PRF Changes	Attachment B - 2016 NHAMCS ED PRF Changes.pdf		Yes	Yes	Fillable Printable
Instruction			Attachment F - 2016 NHAMCS ED PRF Sample Card.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health Resources Utilization Statistics (09-20-0167)	FR Citation: 49 FR 37693

Number of Respondents: 33	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,300	3,300
Annual IC Time Burden (Hours)	385	385
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.