Information Collection

57.400 Outpatient Procedure - Annual Facility Survey

IC 208404 under ICR 202402-0920-011 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey	Form
Form CDC 57.400 57.400 Outpatient Procedure - Annual Facility Survey	Form
CDC 57.400 Outpatient Procedure Component - Annual Facility Survey 57.400_ASCFacSurv_BLANK.DOCX	Form
CDC 57.400 Outpatient Procedure Component - Annual Facility Survey 57.400_ASCFacSurv_BLANK.DOCX	Form
G17. Outpatient Procedure Component.pdf Att G17_Outpatient Procedure Component	IC Document
G17. Outpatient Procedure Component.pdf Att G17_Outpatient Procedure Component	IC Document

IC Title:

57.400 Outpatient Procedure - Annual Facility Survey

Agency IC Tracking Number:

0920-0666

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC 57.400	Outpatient Procedure Component - Annual Facility Survey	57.400_ASCFacSurv_BLANK.DOCX		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 350

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	350	350
Annual IC Time Burden (Hours)	58	58
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att G17_Outpatient Procedure Component	G17. Outpatient Procedure Component.pdf	08/08/2016

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