0920-0853 Emergency Department Visits Reporting Form

Asthma Information Reporting System (AIRS)

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0853 can be found here:

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STATE	[Year] Emergency Department Data
STATE	[Year] Emergency Department Data

	SM Weight	N of ED Visits	[Year] Pop.	Crude Rate
Total		0		#DIV/0!
Age groups
.Under 5 years				#DIV/0!
.5 to 9 years				#DIV/0!
.10 to 14 years				#DIV/0!
.15 to 17 years				#DIV/0!
.18 to 19 years				#DIV/0!
.20 to 24 years				#DIV/0!
.25 to 29 years				#DIV/0!
.30 to 34 years				#DIV/0!
.35 to 39 years				#DIV/0!
.40 to 44 years				#DIV/0!
.45 to 49 years				#DIV/0!
.50 to 54 years				#DIV/0!
.55 to 59 years				#DIV/0!
.60 to 64 years				#DIV/0!
.65 to 69 years				#DIV/0!
.70 to 74 years				#DIV/0!
.75 to 79 years				#DIV/0!
.80 to 84 years				#DIV/0!
.85 years or more				#DIV/0!
*First listed Dx of asthma only (ICD-10-CM code J45)				#DIV/0!
*Only provide hospitalizations that occurred among in-state residents			Age-adjusted Rate per 100,000
*CLICK HERE TO COMPLETE EXCEL SHEET LABELED 'TECHNICAL NOTES'*

Emergency Department Data Technical Notes
1. Indicate coding scheme used for [Year] data:
	All data was coded only using ICD-10-CM
	Other; specify:
2. Types of hospitals not contained in this data (check all that apply):
	Veteran’s Administration Hospitals
	Military hospitals
	Psychiatric/mental health hospitals
	Prison hospitals
	Indian Health Service Hospital
	Other; specify:
3. Does the data include emergency department visits that occurred for in-state residents that occurred out-of-state emergency departments?
	Yes
	No
Additional technical notes:




*CLICK HERE TO RETURN TO EXCEL SHEET LABELED 'CA ED DATA'*

File Type	application/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified	0000-00-00
File Created	0000-00-00