Field Feasibility Test Hospital Records Form

The NHANES Longitudinal Study – Feasibility Component

Documents and Forms

Document Name Document Type
Field Feasibility Test Hospital Records Form Form and Instruction
Hospitalization Record Return Form Att 8b_Request Hospital Record_170209.docx Form and Instruction
Att 8a_Hospital Records Info_170209.docx Participant Information Sheet about the Hospital Records Request IC Document

Information Collection (IC) Details

IC Title:	Field Feasibility Test Hospital Records Form	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	N/A	Hospitalization Record Return Form	Att 8b_Request Hospital Record_170209.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

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

Number of Respondents: 360	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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	360	360
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	2,787	2,787

Documents for IC

Title	Document	Date Uploaded
Participant Information Sheet about the Hospital Records Request	Att 8a_Hospital Records Info_170209.docx	02/27/2017

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