ED Patient Record Form

National Hospital Ambulatory Medical Care Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0278 can be found here:

Documents and Forms

Document Name Document Type
Form NHAMCS 100 (ED) ED Patient Record Form Form
NHAMCS 100 (ED) ED Patient Record Form NHAMCS Attach N 2009 100ed .pdf Form
NHAMCS Att N Cover sheet 2009 100(ED).doc Coversheet IC Document

Information Collection (IC) Details

IC Title:	ED Patient Record Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NHAMCS 100 (ED)	ED Patient Record Form	NHAMCS Attach N 2009 100ed .pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health Resources Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 220	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	22,000	0	22,000
Annual IC Time Burden (Hours)	2,567	367	2,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Coversheet	NHAMCS Att N Cover sheet 2009 100(ED).doc	07/23/2008

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.