OPD 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⚠️ Notice: This information collection may be referencing outdated material.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
OPD Patient Record Form Form
OPD Patient Record NHAMCS 2011 Lab Att A 070610.docx Form
NHAMCS2010 Attachment R - NHAMCS-123.pdf Att. R. OPD Instruction Booklet IC Document

Information Collection (IC) Details

IC Title:	OPD 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	none	OPD Patient Record	NHAMCS 2011 Lab Att A 070610.docx		Yes	No	Paper 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: 128	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	25,600	0	25,600
Annual IC Time Burden (Hours)	3,840	1,280	2,560
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Att. R. OPD Instruction Booklet	NHAMCS2010 Attachment R - NHAMCS-123.pdf	06/08/2009

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