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20XX Annual Hospital Interview (AHI)
Notice – CDC estimates the average public reporting burden for this collection of information as 60 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 H21-8, Atlanta, GA 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 or CIPSEA (44 U.S.C. 3561-3583). 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.
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DO NOT use this worksheet to respond to the survey, it is intended to assist you with gathering and
preparing your data prior to reporting online. Responses to the Annual Hospital Interview
(AHI) questions must be entered into the AHI Portal in order to complete the AHI. Do not send any
data through email.
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Form Approved
OMB No. 0920-0212
Exp. date XX/XX/20XX
The National Center for Health Statistics is inviting you to complete the Annual Hospital
Interview (AHI) for the National Hospital Care Survey. The AHI is a supplemental component of
the National Hospital Care Survey. Data collected on the AHI will be used for statistical purposes
to produce national estimates and obtain further insight on hospitals sampled in the National
Hospital Care Survey.
We want to know how many patient visits this hospital had in the emergency department,
outpatient department, and inpatient department between January 1 – December 31, 20XX
(calendar year 20XX).
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ϭ͘ Was this hospital open for the full calendar year 20XX?
o Yes [Go to Q3]
o No [Go to Q2]
Ϯ͘ Please enter the date range this hospital was open in 20XX:
o [start date] – [end date]
ϯ͘ For 20XX can this hospital separate counts of emergency department visits from counts of
outpatient department visits?
o Yes [Go to Q4]
o No [Go to Q5]
1
ƚƚͲŶŶƵĂů,ŽƐƉŝƚĂů/ŶƚĞƌǀŝĞǁ
Do Not Use to Report - For Informational Purposes ONLY
Annual Hospital Interview (AHI)
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ϰ͘ For 20XX, please provide the number of visits for the following:
Please enter a whole number.
o Emergency department:
o Outpatient department:
ϱ͘ For 20XX, please provide the number of visits for the following:
Please enter a whole number.
o Outpatient and Emergency department:
ϲ͘ For 20XX, can this hospital separate counts of live births from counts of inpatient
discharges?
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o Yes [Go to Q7]
o No [Go to Q8]
ϳ͘ For 20XX, please provide the number of visits for the following:
Please enter a whole number.
o Live births:
o Inpatient discharges:
ϴ͘ For 20XX, please provide the number of visits for the following:
Please enter a whole number.
o Inpatient discharges:
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Now we will ask a question about the use of telemedicine in this hospital in 20XX.
ϵ͘ For 20XX, did this hospital use telemedicine technology (e.g., audio, audio with video,
web videoconference) for patient visits?
o Yes [Go to Q11]
o No Æ Finished
o Don’t know Æ Finished
2
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20XX Annual Hospital Interview (AHI)
o
o
o
o
Emergency department [If selected, answer Q11-12]
Outpatient department [If selected, answer Q13-14]
Inpatient department [If selected, answer Q15-16]
Don’t know Æ Finished
ϭϭ͘ For 20XX, in the emergency department, what types of telemedicine tools did this hospital use for
patient visits? Select all that apply.
Please select “Other tools(s)” and enter information about the other type(s) of telemedicine tool(s) in the text
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ϭϬ͘ For 20XX, in what setting(s) did this hospital use telemedicine technology for patient visits? Select
all that apply.
box if this hospital’s emergency department uses one or more types of telemedicine tools that are not listed.
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o
o
o
o
Telephone audio
Videoconference software with audio (e.g., Zoom, WebEx, FaceTime)
Telemedicine platform NOT integrated with EHR (e.g., Doxy.me)
Telemedicine platform integrated with EHR (e.g., update clinical documentation during
telemedicine visit)
o Other tool(s):
o Don’t know
ϭϮ͘ For 20XX, in the emergency department, what percentage of this hospital’s patient visits were
through telemedicine technology?
Less than 25%
25% to 49%
50% to 74%
75% or more
Don’t know
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o
o
o
o
o
3
Do Not Use to Report - For Informational Purposes ONLY
20XX Annual Hospital Interview (AHI)
patient visits? Select all that apply.
Please select “Other tools(s)” and enter information about the other type(s) of telemedicine tool(s) in the text
box if this hospital’s outpatient department uses one or more types of telemedicine tools that are not listed.
o
o
o
o
Telephone audio
Videoconference software with audio (e.g., Zoom, WebEx, FaceTime)
Telemedicine platform NOT integrated with EHR (e.g., Doxy.me)
Telemedicine platform integrated with EHR (e.g., update clinical documentation during
telemedicine visit)
o Other tool(s):
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ϭϯ͘ For 20XX, in the outpatient department, what types of telemedicine tools did this hospital use for
o Don’t know
through telemedicine technology?
Please select “Don’t know” if you do not know what percentage of this hospital’s outpatient department visits
were through telemedicine technology.
o
o
o
o
o
Less than 25%
25% to 49%
50% to 74%
75% or more
Don’t know
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ϭϰ͘ For 20XX, in the outpatient department, what percentage of this hospital’s patient visits were
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4
Do Not Use to Report - For Informational Purposes ONLY
20XX Annual Hospital Interview (AHI)
patient discharges? Select all that apply.
Please select “Other tools(s)” and enter information about the other type(s) of telemedicine tool(s) in the text
box if this hospital’s inpatient department uses one or more types of telemedicine tools that are not listed.
o
o
o
o
Telephone audio
Videoconference software with audio (e.g., Zoom, WebEx, FaceTime)
Telemedicine platform NOT integrated with EHR (e.g., Doxy.me)
Telemedicine platform integrated with EHR (e.g., update clinical documentation during
telemedicine visit)
o Other tool(s):
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ϭϱ͘ For 20XX, in the inpatient department, what types of telemedicine tools did this hospital use for
o Don’t know
o
o
o
o
o
Less than 25%
25% to 49%
50% to 74%
75% or more
Don’t know
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ϭϲ͘ For 20XX, in the inpatient department, what percentage of this hospital’s patient discharges were
through telemedicine technology?
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5
| File Type | application/pdf |
| File Title | 2023-AHI-Preview-Questionnaire |
| Subject | Annual Hospital Interview, National Hospital Care Survey, National Center for Health Statistics |
| Author | National Center for Health Statistics |
| File Modified | 2024-02-06 |
| File Created | 2024-01-18 |