Information Collection

Patient Record Form (NAMCS-1)

IC 220063 under ICR 201602-0920-006 · OMB 0920-0234.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	0920-0234	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 %

table that charts list of burden
	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

table that charts IC Documents
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.