National Hospital Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0212 Initial Hospital Intake Questionnaire	Form and Instruction	Modified	Available
Annual FSASC Interview	Form	Removed	Available
Form 0920-0212 Prepare and Transmit EHR for Inpatient and Ambulatory	Form and Instruction	Modified	Available
Form 0920-0212 Annual Ambulatory Hospital Interview	Form and Instruction	Modified	Available
Form 0920-0212 Annual Hospital Interview	Form and Instruction	Modified	Available
Form 0920-0212 Prepare and transmit UB-04 or State File for Inpatient and Ambulatory	Form and Instruction	Modified	Repair queued
Form 0920-0212 Recruitment Survey Presentation	Form and Instruction	Modified	Available
Attachment V - OPD PRF Changes 010616.docx	Supplementary Document	Uploaded 2016-01-07	Available
Att U - ED Patient Record Form Changes.docx	Supplementary Document	Uploaded 2016-01-07	Available
Att T - Amb Hosp Induction Inter Changes.docx	Supplementary Document	Uploaded 2016-01-07	Available
Attachment S - NHCS FAQ Brochure 010716.pdf	Supplementary Document	Uploaded 2016-01-07	Available
Attachment R - Outpt Dept Pt Record Form 010616.docx	Supplementary Document	Uploaded 2016-01-07	Available
Attachment Q - Emer Dept Pt Record Form 010616.docx	Supplementary Document	Uploaded 2016-01-07	Available
Attachment J - Annual Hosp Inter 010616.docx	Supplementary Document	Uploaded 2016-01-07	Available
Attachment I - List of Varfor EHR Ext OPD Visits 010616.docx	Supplementary Document	Uploaded 2016-01-07	Available
Attachment H - List of Var for EHR Ext of ED Visits 010616.docx	Supplementary Document	Uploaded 2016-01-07	Available
Attachment G - List of Var for EHR Ext of IP Disch 010616.docx	Supplementary Document	Uploaded 2016-01-07	Available
Attachment E - Amb Intro Letter to Hosp EDs OPDs 010616.docx	Supplementary Document	Uploaded 2016-01-07	Available
Attachment D - Intro Letter to Hosp 010616.docx	Supplementary Document	Uploaded 2016-01-07	Available
Att Z - Proposed changes Initial Hospital Intake Questionnaire.docx	Supplementary Document	Uploaded 2015-11-12	Available
Att Y - Proposed changes Annual Hospital Interview.docx	Supplementary Document	Uploaded 2015-11-12	Available
Att M- ERB Approval UPDATED 10 26 15.pdf	Supplementary Document	Uploaded 2015-11-12	Available
Att F - Currently Approved UB04 Data Elements.docx	Supplementary Document	Uploaded 2015-11-12	Available
Att X - Background and Historical Information.docx	Supplementary Document	Uploaded 2015-11-12	Available
Att L - Westat Data Security Plan.pdf	Supplementary Document	Uploaded 2015-11-12	Available
Att C - Data Collection Flow Chart.docx	Supplementary Document	Uploaded 2015-11-12	Repair queued
0920-0212 SSB 010616.docx	Supporting Statement B	Uploaded 2016-01-07	Available
0920-0212 SSA 010616.docx	Supporting Statement A	Uploaded 2016-01-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6666	Initial Hospital Intake Questionnaire	Form and Instruction	Modified
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 EHR for Inpatient and Ambulatory	Form and Instruction	Modified
186284	Annual Ambulatory Hospital Interview	Form and Instruction	Modified
186283	Annual Hospital Interview	Form and Instruction	Modified
186282	Prepare and transmit UB-04 or State File for Inpatient and Ambulatory	Form and Instruction	Modified
186281	Recruitment Survey Presentation	Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0212	ICR Reference No: 201511-0920-007
Status: Historical Active	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: Approved without change	Conclusion Date: 01/07/2016
	Date Received in OIRA: 11/19/2015
Terms of Clearance: NCHS will communicate regularly with OMB about the outcome of its effort to combe NHAMCS with the NHCS, particularly progress in recruiting hospitals and their ability to efficiently transfer data to NCHS, as well as the expected timing of combining these ICRs as well as its progress on developing the frame for the free standing ambulatory care facilities.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2019	36 Months From Approved	04/30/2016
Responses	7,458	0	131,516
Time Burden (Hours)	8,232	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).

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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:
	79 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
Recruitment Survey Presentation	0920-0212	Att O - Recruitment Survey Pres
Prepare and transmit UB-04 or State File for Inpatient and Ambulatory	0920-0212	Att P - Mth Data Trans of UB-04 Data
Annual Hospital Interview	0920-0212	Att J - Proposed Final Annual Hospital Interview
Annual Ambulatory Hospital Interview	0920-0212	Att K - Ann Amb Hosp Inter
Prepare and Transmit EHR for Inpatient and Ambulatory	0920-0212	Att W - Qtr Data Trans of EHR Data
Annual FSASC Interview	none	Annual FSASC Interview
FSASC Pulling and Refiling Patient Records
Pulling and re-filing Patient Records (ED, OPD, and ASL)
FSASC Prepare and Transmit UB-40
Initial Hospital Intake Questionnaire	0920-0212	Att N - Proposed Final Initial Hosp Intake Ques

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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	7,458	131,516	0	-124,058	0	0
Annual Time Burden (Hours)	8,232	7,224	0	1,008	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: The currently approved burden is 7,224 hours; the proposed burden for the NHCS is 8,232 hours per data collection year; 1,975 hours were subtracted as a result of the removal of several line items (Ambulatory Unit Induction, Pulling and re-filing Patient Records [ED, OPD, and ASL], Annual FSASC Interview, Prepare and transmit UB-04, and Pulling and re-filing Patient Records); 2,983 hours were added as result of the change to monthly data transmission for UB-04 claims as well as increasing the sample to 581 hospitals. This results in a net increase of 1,008 burden hours.

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Annual Cost to Federal Government: $6,500,000

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]? 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)? 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: 11/19/2015

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