National Hospital Care Survey

Forms and Documents

Document Name	Status
Initial Hospital Intake Questionnaire Form	Modified
Annual FSASC Interview Form	New
Prepare and transmit UB-04 for Inpatient and Ambulatory Form	Modified
Ambulatory Unit Induction Form	Modified
Annual Ambulatory Hospital Interview Form	Modified
Annual Inpatient Hospital Interview Form	Modified
Recruitment Survey Presentation Form	Modified
NHCS 2013 - 2015 Supporting Statement Part B Final 0 4 12 13.docx Supporting Statement B	2013-04-15
Attachment U- NHCS FAQ Brochure .pdf Supplementary Document	2013-01-31
Attachment T - AS Patient Record Form.docx Supplementary Document	2013-01-31
Attachment S - OPD Patient Record form.docx Supplementary Document	2013-01-31
Attachment R - ED Patient Record form.docx Supplementary Document	2013-04-15
Attachment H- ERB Approval Notice for NHCS .pdf Supplementary Document	2013-01-30
Attachment G- Westat Data Security Plan .pdf Supplementary Document	2013-01-30
Attachment F - Hospital Ambulatory Data Collection Flow Chart.docx Supplementary Document	2013-04-15
Attachment E- Intro Letter to FSASCs.docx Supplementary Document	2013-01-30
Attachment D - Ambulatory Intro Letter to Hospitals EDs OPDs ASLs.docx Supplementary Document	2013-01-30
Attachment C- Intro Letter to Hospitals.docx Supplementary Document	2013-01-30
Attachment B- Federal Register Notice for NHCS.pdf Supplementary Document	2013-01-30
Attachment A - Legislative Authority to Collect Data on Hospital Utilization.rtf Supplementary Document	2013-01-30
Attachment Q- List of UB04 Data Elements.docx Supplementary Document	2013-01-31
Attachment Q- List of UB04 Data Elements.docx Supplementary Document	2013-01-31
NHCS 2013 - 2015 Supporting Statement Part A__Revised 032713_LM.DOCX Supporting Statement A	2013-04-15

IC Document Collections

IC ID	Document Title	Status
6666	Initial Hospital Intake Questionnaire Form	Modified
205650	FSASC Pulling and Refiling Patient Records Instruction	New
205649	FSASC Prepare and Transmit UB-40 Instruction	New
205648	Annual FSASC Interview Form	New
205647	Pulling and re-filing Patient Records (ED, OPD, and ASL) Instruction	New
186285	Prepare and transmit UB-04 for Inpatient and Ambulatory Form	Modified
186284	Ambulatory Unit Induction Form	Modified
186283	Annual Ambulatory Hospital Interview Form	Modified
186282	Annual Inpatient Hospital Interview Form	Modified
186281	Recruitment Survey Presentation Form	Modified

ICR Details

OMB Control No: 0920-0212	ICR Reference No: 201302-0920-001
Status: Historical Active	Previous ICR Reference No: 201104-0920-011
Agency/Subagency: HHS/CDC	Agency Tracking No: 18672
Title: National Hospital Care Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/15/2013
	Date Received in OIRA: 02/01/2013
Terms of Clearance: NCHS will communicate regularly with OMB about outcome of its preliminary work regarding combining NHAMCS with the NHCS, and the expected timing of combining these ICRs as well as its progress on developing the frame for the free standing ambulatory care facilities.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2016	36 Months From Approved	04/30/2014
Responses	131,516	0	2,711
Time Burden (Hours)	7,224	0	3,520
Cost Burden (Dollars)	0	0	0

---

Abstract: NCHS requests approval to continue the NHCS and to begin to integrate the NHAMCS into NHCS as part of a broader strategy to improve efficiency by minimizing redundancy in data collection, broadening capability to collect more relevant data on transitions in care, and identifying opportunities to exploit administrative and electronic clinical data systems. NHCS will electronically collect administrative claims data, but as hospitals adopt EHRs, it will be poised to accept electronic files. In 2013 NHAMCS will operate in tandem with the ambulatory component of NHCS so data from the two surveys can be compared.

---

Authorizing Statute(s): US Code: 42 USC 242k Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 61411	10/09/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 6327	01/30/2013
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Annual FSASC Interview	none	Annual FSASC Interview
Annual Ambulatory Hospital Interview	none, none	Annual Ambulatory Hospital Interview
Ambulatory Unit Induction	none	Ambulatory Unit Induction
Prepare and transmit UB-04 for Inpatient and Ambulatory	none	Quarterly Transmission of UB-04 Data
Pulling and re-filing Patient Records (ED, OPD, and ASL)
Initial Hospital Intake Questionnaire	none	Initial Hospital Intake
Recruitment Survey Presentation	none	Recruitment Survey Presentation
Annual Inpatient Hospital Interview	none	Annual Inpatient Hospital Interview
FSASC Pulling and Refiling Patient Records
FSASC Prepare and Transmit UB-40

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	131,516	2,711	0	128,805	0	0
Annual Time Burden (Hours)	7,224	3,520	0	3,704	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The increase in burden is due to hospital outpatient and emergency departments and Freestanding Ambulatory Surgery facilities that will be included in the NHCS.

---

Annual Cost to Federal Government: $9,173,000

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]? Yes

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)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 02/01/2013

---