Information Collection

Monthly template for ambulatory care EHR data extracts (updated

IC 236387 under ICR 201906-0935-002 · OMB 0935-0238.

Documents and Forms

Document Name Document Type
Form Attachment M Monthly template for ambulatory care EHR data extracts (updated Form and Instruction
Attachment M Attachment M: Monthly template for ambulatory care EHR d Attachment M ambulatory care monthly template.1.xlsx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Monthly template for ambulatory care EHR data extracts (updated	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	Attachment M	Attachment M: Monthly template for ambulatory care EHR data extracts (updated)	Attachment M ambulatory care monthly template.1.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 167	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: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,505	2,505
Annual IC Time Burden (Hours)	2,505	2,505
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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