Patient Record Form (NAMCS-1)

National Ambulatory Medical Care Survey (NAMCS)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0234 Patient Record Form (NAMCS-1) Form and Instruction
0920-0234 Att D2 2016 NAMCS PRF Att D2 2016 NAMCS PRF 122115.docx Form and Instruction
Att D3 - 2016 NAMCS PRF Final.docx Att D3 - 2016 NAMCS PRF Final IC Document

Information Collection (IC) Details

IC Title:	Patient Record Form (NAMCS-1)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	0920-0234	Att D2 2016 NAMCS PRF	Att D2 2016 NAMCS PRF 122115.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Human Resources Utilzation 09-20-0167	FR Citation: 49 FR 37697

Number of Respondents: 23	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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	690	690
Annual IC Time Burden (Hours)	161	161
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att D3 - 2016 NAMCS PRF Final	Att D3 - 2016 NAMCS PRF Final.docx	02/10/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.