National Hospital Ambulatory Medical Care Survey

Forms and Documents

Document Name	Status
OPD Patient Record Form Form	Modified
ASL Patient Record Form Form	Modified
ED Patient Record Form Form	Modified
Hospital Induction Form Form	Modified
Form unnumbered Cervical Cancer Screening Supplement Form	Removed
NHAMCS 2014 nonsub supp statement 103013.doc Justification for No Material/Nonsubstantive Change	2013-10-30
Attachment D - ASL PRF Changes.docx Supplementary Document	2013-10-30
Attachment C - ED PRF Changes.docx Supplementary Document	2013-10-30
Attachment B - OPD PRF Changes.docx Supplementary Document	2013-10-30
Attachment A - NHAMCS EHR changes 102513.docx Supplementary Document	2013-10-30

IC Document Collections

IC ID	Document Title	Status
43613	Ambulatory Unit Induction Instruction	Modified
201697	Medical Record Reabstraction Instruction	Modified
201696	Reabstraction Telephone Call Instruction	Modified
181868	Pulling and re-filing Patient Records Instruction	Modified
181867	OPD Patient Record Form Form	Modified
181866	ASL Patient Record Form Form	Modified
181865	ED Patient Record Form Form	Modified
181864	Hospital Induction Form Form	Modified
181863	Cervical Cancer Screening Supplement Form	Removed

ICR Details

OMB Control No: 0920-0278	ICR Reference No: 201311-0920-002
Status: Historical Active	Previous ICR Reference No: 201210-0920-009
Agency/Subagency: HHS/CDC	Agency Tracking No: 20786
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: Approved without change	Conclusion Date: 11/05/2013
	Date Received in OIRA: 11/05/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	12/31/2014	12/31/2014
Responses	132,443	0	132,698
Time Burden (Hours)	7,352	0	8,456
Cost Burden (Dollars)	0	0	0

---

Abstract: This request is for approval of minor changes for 2014. The National Hospital Ambulatory Medical Care Survey (NHAMCS) is a national survey of patient visits to emergency departments, outpatient departments, and ambulatory surgery locations of general and short-stay hospitals, as well as freestanding ambulatory surgery centers.

---

Authorizing Statute(s): US Code: 42 USC 306 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

Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Ambulatory Unit Induction
Hospital Induction Form	none	Hospital Induction Interview
Cervical Cancer Screening Supplement	unnumbered	Att. T. Cervical Cancer Screening Supplement
ED Patient Record Form	none	ED Screenshots
ASL Patient Record Form	none	Ambulatory Surgery
OPD Patient Record Form	none	OPD Screenshots
Pulling and re-filing Patient Records
Reabstraction Telephone Call
Medical Record Reabstraction

---

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	132,443	132,698	0	-255	0	0
Annual Time Burden (Hours)	7,352	8,456	0	-1,104	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This change request results in a reduction in burden due to changes in one form. In addition, burden was not adjusted previously for one temporary component of this data collection and this also reduces the currently approved burden.

---

Annual Cost to Federal Government: $6,032,000

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? Yes

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)? Yes

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: 11/05/2013

---