Attachment F: Annual Hospital Interview
Form Approved
OMB No. 0920-0212
Exp. date XX/XX/20XX
Notice - CDC estimates the average public reporting burden for this collection of information as 2 hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0212). Assurance of confidentiality- We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. |
Part 1. Hospital Utilization Statistics
1. What is the number of currently staffed inpatient beds in this hospital, not including “newborn” bassinets?
a) Total staffed inpatient beds: ________________
b) If you submit data combined with other hospital(s), what is the number of currently staffed inpatient beds, not including “newborn” bassinets, for all the hospitals that report together?
Combined total staffed inpatient beds: _______________
2. What was the average length of stay (in days) for inpatients in this hospital in calendar year 2019?
______________________________
Part 2. General Questions
3. What is the primary service type of this hospital?
General acute care
Specialty acute care hospital (e.g., surgical, maternity, cancer, heart, ENT, orthopedic, etc…)
Children’s hospital (including general, orthopedic, ENT, cancer, heart, and other acute care)
Psychiatric hospital (including children’s psychiatric and alcohol/chemical dependency)
Long term acute care (including adult and children’s rehabilitation, chronic disease, TB)
4. Was this hospital open for the full calendar year 2019?
Yes
No Please provide the dates the hospital was open for inpatient service in 2019: ______________________________________________
Never open in 2019
5. In the past year, has this hospital merged with or separated from another hospital?
Merger Please continue with item 5a below.
Separation Please continue with item 5a below.
Neither Please proceed to item 7.
5a. Please provide the name(s) and address(es) of the other hospital(s) involved:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
6. What is the primary service type(s) of the other hospital(s) involved? Check all that apply.
General acute care
Specialty hospital (e.g. surgical, maternity, cancer, heart, ENT, orthopedic, etc…)
Children’s hospital (including general, orthopedic, ENT, cancer, heart, and other acute care)
Psychiatric hospital (including children’s psychiatric and alcohol/chemical dependency)
Long term acute care (including adult and children’s rehabilitation, chronic disease, TB)
7. In calendar year 2019, did your facility have any significant changes to the total number of inpatient beds?
Yes Please explain_____________________________________________
No
8. Do you anticipate any significant changes in your discharge volume in the coming year (for example, opening a cardiac wing or closing a birthing center)?
Yes Please explain_____________________________________________
No
Part 3. Data Reporting
9. When this hospital reports data to the State or to the hospital association, is the information solely for this hospital or are other hospital(s) included in the data submission?
Solely for this hospital
Combined with other hospital(s) Please provide the name(s) of the other hospital(s):
__________________________________________________________________
__________________________________________________________________
10. Do the data you provide to us include records from your hospital only?
Yes Please proceed to item 11 below.
No Please continue with item 10a below.
Don’t know
10a. Is it possible to identify the records from your hospital separate from the other hospital(s) that report with you?
Yes No Don’t know
11. Do the inpatient data you send to us include records for all discharges (including those paying with public or private insurance as well as self-pay, charity, workmen’s compensation, and court or law enforcement)?
Yes No (skip to 11b)
11a. If yes, how many (or approximately what percent) of the records you sent us for the calendar year 2019 were paid with public or private insurance (excluding workmen’s compensation)?
___________________________
11b. If no, then approximately what number or percent of total records (including those for records not submitted) for the calendar year 2019 were for other forms of payment (self-pay, charity, workmen’s compensation, and/or court or law enforcement)?
___________________________
12. Do the ambulatory data you send to us include records for all visits (including those paying with public or private insurance as well as self-pay, charity, workmen’s compensation, and court or law enforcement)?
Yes No (skip to 12b)
12a. If yes, how many (or approximately what percent) of the records you sent us for the calendar year 2019 were for visits paid with public or private insurance (excluding workmen’s compensation)?
___________________________
12b. If no, then approximately what number or percent of total claims (including those for records not submitted) for the calendar year 2019 were for other forms of payment (self-pay, charity, workmen’s compensation, and/or court or law enforcement)?
___________________________
13. Please provide the counts or estimates for ED visits by quarter or year for calendar year 2019 for the following categories.
If you cannot separate ED visits from all Outpatient visits, please check here.
Number of ED VISITS for: |
Annual |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
All visits made to ED |
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Insured patients (public and private, exclude workmen’s compensation) |
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All other forms of payment (self-pay, charity, court/law enforcement) |
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14. Please provide the counts or estimates for OPD visits by quarter or year for calendar year 2019 for the following categories.
If you cannot separate OPD visits from all Outpatient visits, please check here.
Number of OPD VISITS for: |
Annual |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
All visits made to OPD |
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Insured patients (public and private, exclude workmen’s compensation) |
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All other forms of payment (self-pay, charity, court/law enforcement) |
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15. In calendar year 2019, does your hospital have a birthing unit or offer obstetric services for females with deliveries?
Yes No
15a. Please provide the total number of inpatient discharges (including live births) or the total number of admissions (and live births) by month or annually for calendar year 2019.
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Total number of inpatient discharges (including live births) |
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Total number of admissions |
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Total Number of Live births |
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February
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March
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April
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May
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August
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September
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October
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November
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December
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Monica Wolford |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |