Att. K. Patient Visit Log

OMB No. 0920-0278

Sheet________of________sheets

NOTICE – Public reporting burden of this collection of information is included in
the 60 minute burden associated with the Ambulatory Unit Record, including the
time for reviewing instructions, searching existing data sources, gathering and
maintaining the data 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).

NHAMCS-103

FORM
(10-20-2008)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

Assurance of confidentiality – All information which
would permit identification of an individual, a practice, or an
establishment will be held confidential, will be used for
statistical purposes 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 Effciency Act (PL-107-347).

1. Clinic/Service Area/ASC Name

U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR THE

NATIONAL CENTER FOR
HEALTH STATISTICS

2. Sampling Take Every

3. Random Start Number

CENTERS FOR DISEASE CONTROL
AND PREVENTION

PATIENT VISIT LOG
NATIONAL HOSPITAL AMBULATORY
MEDICAL CARE SURVEY

NOTE – Hospital is to retain log after completion of study. This log is
for optional use. Put a check mark (⻬) in column (f) "Sample" next to
each patient selected for the sample of visits.

Sample
Line
No.

Date of
visit

Patient name

Patient
record/
identification
number

(a)

(b)

(c)

(d)

USCENSUSBUREAU

Remarks

(e)

Mark (⻬)
for patient(s)
selected for
sample of
visits.
(f)