National Hospital Care Survey

Forms and Documents

Document Name	Status
Form 0920-0212 Initial Hospital Intake Questionnaire Form and Instruction	Modified
Form 0920-0212 Prepare and Transmit EHR for Inpatient and Ambulatory Form and Instruction	Modified
Form 0920-0212 Annual Ambulatory Hospital Interview Form and Instruction	Removed
Form 0920-0212 Annual Hospital Interview Form and Instruction	Modified
Form 0920-0212 Prepare and transmit UB-04 or State File for Inpatient and Ambulatory Form and Instruction	Modified
Form 0920-0212 Recruitment Survey Presentation Form and Instruction	Modified
Att M - Summary Update.docx Supplementary Document	2019-01-29
Att K - Confidentiality Letter.docx Supplementary Document	2019-01-29
Att G - ERB Approval Notice for NHCS.pdf Supplementary Document	2019-01-29
Att E- EHR Variable List.pdf Supplementary Document	2019-01-29
Att D - Currently Approved UB04 Data Elements.docx Supplementary Document	2019-01-29
Att C - Introductory Letter to Hospitals.docx Supplementary Document	2019-01-29
Att B2 - 60-day Federal Register Notice Comments.docx Supplementary Document	2019-01-29
Att B1- 60-Day FRN for NHCS 120718.pdf Supplementary Document	2019-01-29
Att A - Legislative Authority to Collect Data on Hospital Utilization.rtf Supplementary Document	2019-01-29
0920-0212_Statement B_02.27.2019.docx Supporting Statement B	2019-03-05
0920-0212_Statement A_02.27.2019.docx Supporting Statement A	2019-03-05

IC Document Collections

IC ID	Document Title	Status
6666	Initial Hospital Intake Questionnaire Form and Instruction	Modified
186285	Prepare and Transmit EHR for Inpatient and Ambulatory Form and Instruction	Modified
186284	Annual Ambulatory Hospital Interview Form and Instruction	Removed
186283	Annual Hospital Interview Form and Instruction	Modified
186282	Prepare and transmit UB-04 or State File for Inpatient and Ambulatory Form and Instruction	Modified
186281	Recruitment Survey Presentation Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0212	ICR Reference No: 201901-0920-008
Status: Historical Active	Previous ICR Reference No: 201511-0920-007
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0212
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: 03/05/2019
	Date Received in OIRA: 01/30/2019
Terms of Clearance: NCHS will continue to update OMB regularly regarding challenges with and progress toward recruiting hospitals and their ability to efficiently transfer data to NCHS, as well as its progress on developing the sampling frame for free standing ambulatory care facilities.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2022	36 Months From Approved	03/31/2019
Responses	6,482	0	7,458
Time Burden (Hours)	7,080	0	8,232
Cost Burden (Dollars)	0	0	0

---

Abstract: The goal of the National Hospital Care Survey (NHCS) is to assess the health of the population through the creation of a dataset that contains information on health care utilization as well as the demographic characteristics, medical conditions, and treatment of patients who use hospitals for inpatient and ambulatory medical care in the United States. This Revision requests the following: • Continue recruitment of hospitals in the sample for the NHCS. • Continue the collection of hospital-level data through an initial intake questionnaire and an Annual Hospital Interview for all sampled hospitals. • Continue the collection of electronic data on inpatient discharges as well as Emergency Department (ED) and Outpatient Department (OPD) visits through the collection of Electronic Health Record (EHR) data, UB-04 claims, or a state file. • Continue collection of substance-involved ED visit data through the ED component. • Eliminate the “Annual Ambulatory Hospital Interview” (578 hours of burden) administered as part of medical record abstraction of a sample of ED and OPD visits. • Postpone frame development for free-standing ambulatory care facilities. • Continue to make relatively minor additions, deletions, and changes to the survey through the use of non-substantive change submissions.

---

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:
	83 FR 46488	09/13/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 455	01/29/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Annual Ambulatory Hospital Interview	0920-0212	Att K - Ann Amb Hosp Inter
Initial Hospital Intake Questionnaire	0920-0212	Initial Hospital Intake Questionnaire 2019
Recruitment Survey Presentation	0920-0212	Recruitment Survey Presentation 2019
Prepare and transmit UB-04 or State File for Inpatient and Ambulatory	0920-0212	UB-04 or State File for Inpatient and Ambulatory (monthly)
Annual Hospital Interview	0920-0212	Annual Hospital Interview 2019
Prepare and Transmit EHR for Inpatient and Ambulatory	0920-0212	EHR for Inpatient and Ambulatory (quarterly)

---

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	6,482	7,458	0	-976	0	0
Annual Time Burden (Hours)	7,080	8,232	0	-1,152	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: Revision of 0920-0212 (NHCS) results in a net decrease of 1,152 Burden Hours due to the removal of the Annual Ambulatory Hospital Interview (578 hours); reduction of the number of hospitals receiving the Intake Questionnaire (10 hours) or Recruitment Survey Presentation (10 hours); and a decrease in the number of hospitals transmitting UB-04 claims (984 hours). There were 430 hours added as a result of more hospitals in the sample submitting EHR data (396 hours) and the slight increase in sample size requiring more hospitals to complete the Annual Hospital Interview (34 hours).

---

Annual Cost to Federal Government: $7,500,000

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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)? 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: 01/30/2019

---