ATTACHMENT G 6

HOSPITAL INTERVIEW QUESTIONNAIRE

CURRENT NHDS

This statement below will replace the first sentence of the Notice Box when the form is reprinted.

OMB No. 0920-0212: Approval expires 08/31/2008

Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).