Information Collection

2016 Ambulatory Surgery Center Patient Record Form

IC 214304 under ICR 201510-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0278 2016 Ambulatory Surgery Center Patient Record Form	Form and Instruction
Attachment H - 2016 NHAMCS ASL PRF Sample Card.pdf	Instruction
0920-0278 Attachment D - 2016 NHAMCS ASL PRF Changes Attachment D - 2016 NHAMCS ASL PRF Changes.pdf	Form and Instruction

IC Title:

2016 Ambulatory Surgery Center 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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0278	Attachment D - 2016 NHAMCS ASL PRF Changes	Attachment D - 2016 NHAMCS ASL PRF Changes.pdf		Yes	Yes	Fillable Printable
Instruction			Attachment H - 2016 NHAMCS ASL 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: 23

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,300	2,300
Annual IC Time Burden (Hours)	268	268
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.