National Hospital Ambulatory Medical Care Survey

Forms and Documents

Document Name	Status
Form unnumbered Ambulatory Unit Record Form	Modified
Asthma Management Supplement Form	New
Freestanding ASC Induction Form Form	Modified
OPD Patient Record Form Form	Modified
Form unnumbered ASC Patient Record Form Form	Modified
Form unnumbered ED Patient Record Form Form	Modified
Hospital Induction Form Form	Modified
Form unnumbered Cervical Cancer Screening Supplement Form	Modified
Attachment H - NHAMCS-910 Lookback Module-revised.pdf Supplementary Document	2011-05-09
Attachment G - NHAMCS-100(ED)-revised.pdf Supplementary Document	2011-05-09
Attachment F - NHAMCS-100(ASC)-revised.pdf Supplementary Document	2011-05-09
Attachment E - NHAMCS-100(OPD) -rev.pdf Supplementary Document	2011-05-09
NHAMCS Justification for change - pretes t050211.docx Justification for No Material/Nonsubstantive Change	2011-05-09
NHAMCS2010 Attachment R - NHAMCS-123.pdf Supplementary Document	2009-06-08
NHAMCS2010 Attachment S - NHAMCS-126.pdf Supplementary Document	2009-06-08
NHAMCS2010 Attachment Q - NHAMCS-122.pdf Supplementary Document	2009-06-08
NHAMCS2010 Attachment K - NHAMCS-103.pdf Supplementary Document	2009-06-08

IC Document Collections

IC ID	Document Title	Status
43613	Ambulatory Unit Record Form	Modified
197667	Pulling and Refiling Patient Records Pretest Instruction	New
197666	Asthma Management Supplement Form	New
189813	Freestanding ASC Induction Form Form	Modified
181868	Pulling and re-filing Patient Records Instruction	Modified
181867	OPD Patient Record Form Form	Modified
181866	ASC Patient Record Form Form	Modified
181865	ED Patient Record Form Form	Modified
181864	Hospital Induction Form Form	Modified
181863	Cervical Cancer Screening Supplement Form	Modified

ICR Details

OMB Control No: 0920-0278	ICR Reference No: 201105-0920-007
Status: Historical Inactive	Previous ICR Reference No: 201011-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Hospital Ambulatory Medical Care Survey
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 05/26/2011
	Date Received in OIRA: 05/11/2011
Terms of Clearance: to update

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2012	08/31/2012	08/31/2012
Responses	128,141	0	128,141
Time Burden (Hours)	12,112	0	12,112
Cost Burden (Dollars)	0	0	0

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Abstract: This request is to modify/add selected questions on Electronic medical record usage and delete the cancer supplement starting in 2011 to the ongoing OMB 0920-0278 -National Hospital Ambulatory Medical Care Survey (NHAMCS).

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Authorizing Statute(s): US Code: 42 USC 306 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

IC Title	Form No.	Form Name
Asthma Management Supplement	none	Asthma Management Supplement Pretest
Cervical Cancer Screening Supplement	unnumbered	Att. T. Cervical Cancer Screening Supplement
Ambulatory Unit Record	unnumbered, none, none	Att. J. Ambulatory Unit Induction Form ,   Att. J. Ambulatory Unit Induction Form - 11/29/2010 ,   Ambulatory Unit Induction - 5/2011
ASC Patient Record Form	unnumbered, none	Att. O. ASC Patient Record Form ,   ASC Patient Record Form - 5/2011
OPD Patient Record Form	none, none, none	OPD Patient Record ,   OPD Patient Record - 11/29/2010 ,   OPD Patient Record Form - 5/2011
Pulling and re-filing Patient Records
Freestanding ASC Induction Form	none, none, none	Freestanding Ambulatory Surgery Centers Form ,   Freestanding Ambulatory Surgery Centers Form - 11/29/2010 ,   Freestanding Ambulatory Surgery Centers Form - pretest 5/2011
Hospital Induction Form	none, none, none	Hospital Induction Form ,   Hospital Induction Form - 11/29/2010 ,   Hospital Induction Form - 5/2011
ED Patient Record Form	unnumbered, none	Att. M. ED Patient Record Form ,   ED Patient Record Form - 5/2011
Pulling and Refiling Patient Records Pretest

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $4,473,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/11/2011

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