Form 0920-22BT Attachment E - Ambulatory Unit Induction Questionnaire (

2022 National Hospital and Medical Care Survey (NHAMCS)
Ambulatory Unit Induction Questionnaire

Notice – CDC estimates the average public reporting burden for this collection of information as 15 minutes 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, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0278).

 

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 2018 (CIPSEA Pub. L. No. 115-435, 132 Stat. 5529 § 302). 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. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.

Form Approved: OMB No. 0920-0278; Expiration date: 09/30/2023

AMBULATORY UNIT (AU) INDUCTION: EMERGENCY DEPARTMENT (ED)
INTRO_ED	If necessary, introduce yourself and explain the survey. Provide the administrator with the introductory letter and ensure you obtained verbal consent before proceeding with the interview. Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital's emergency department
ESA_MANY	How many emergency service areas at this hospital are open 24 hours a day? (Enter number)
ESA_NUM	ESA number
DEL_ESA	Does (ESA name) still exist and is it still operational? (Enter 97 to delete this ESA)
ESA_NAME	What is the name of this ESA?
ESATYPE	What type of ESA is (ESA name)? 1='General' 2='Adult' 3='Pediatric' 4='Urgent care/Fast track' 5='Psychiatric' 6='Other'
ESA_EVISITS	What is the expected number of visits from (Reporting period start date) to (Reporting period end date) for (ESA name)?
ESA_ADDED_DELETED	Please explain why this ESA has been added or deleted (Interviewer enters brief explanation for why they have added or removed an ESA.)
ROOFS	Can you confirm the following? 1. Revenue: Are all revenues from this ESA facility forwarded directly to the [Fill hospital in sample]? 2. Ownership: Is this ESA facility owned by the [Fill hospital in sample]? (If the hospital owns the property but rents the facility to another medical practice to operate, then this is not to be included as in-scope satellite.) 3. Operation: Is this ESA facility operated by [Fill hospital in sample]? 4. Federal Tax ID: Is the federal tax ID of [Fill hospital in sample] and this ESA facility the same? (An exception to this is when a health system owns several hospitals that all have the same federal tax ID. In this case, only ESAs associated with the sample hospital should be included.) 5. Staff: Is the staff of this ESA facility either paid directly by [Fill hospital in sample] or contracted by [Fill hospital in sample]? (Read all answer categories) (Select or enter all that apply, separate with commas): 1 = ‘Revenue’ 2 = ‘Ownership’ 3 = ‘Operation’ 4 = ‘Federal Tax ID’ 5 = ‘Staff’
I_ESA	ESA name from previous year in panel
I_ESA_EVISITS	Number of visits from previous time in sample
ESA_EVISITS_TOTAL	Total number of ED visits for all eligible ESAs
AU_ONSITE	Is this ESA on-site? 1=Yes 2=No
ESA24B	Is this ESA open 24 hours a day? 1=’Yes’ 2=’No’
DONE_ED	Enter 1 to complete induction for this department WARNING: once you pass this screen, the ED portion of the induction interview will be closed, and you will not be allowed to re-enter to change any answers or add additional AUs. If you need to go back, use your up arrow to go back now, or press F10 to come back in later. DO NOT press 1 if you need to come back to this department section later.
AGREEEST	According to our information, there were (number) patient visits during the reporting period. Is this correct? 1=’Yes’ (Skip to NUMTRLEV) 2=’No’
ESTVISHR	How many visits did you have during the reporting period? (Instrument calculates new sampling pattern for patients’ visits)
NUMTRLEV	How many levels are in this ESA's triage system? 1=’Three’ 2=’Four’ 3=’Five’ 4=’Other – Specify’ (Go to NUMTRLEV_SP) 5=’None Do not conduct triage’
NUMTRLEV_SP	Specify other triage levels

Page 2 of 2