ASC 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⚠️ Notice: This information collection may be referencing outdated material.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 (ASC) ASC Patient Record Form Form and Instruction
NHAMCS 100 (ASC) ASC Patient Record Form NHAMCS Att T 2009 folio Revised-100(ASC).pdf Form and Instruction
NHAMCS Att T Cover sheet 2009 Revised100(ASC).doc Coversheet IC Document

Information Collection (IC) Details

IC Title:	ASC 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 and Instruction	NHAMCS 100 (ASC)	ASC Patient Record Form	NHAMCS Att T 2009 folio Revised-100(ASC).pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

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

Number of Respondents: 107	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	10,700	9,744	956
Annual IC Time Burden (Hours)	1,070	114	956
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Coversheet	NHAMCS Att T Cover sheet 2009 Revised100(ASC).doc	07/24/2008

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