Attachment J - Induction letter for Current Survey

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OMB No.: 0920-0212 Approval Expires 10/31/2011

ational Hospital Discharge Survey Pretest

SAMPLE LISTING SHEET

PART A: Collecting Group Statistics and Determining Sampling Interval

Notice - Public reporting burden for this collection of information is estimated to average 14 minutes per sampled record, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0212).

Assurance of Confidentiality -- All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

For detailed instructions and definitions of terms used in this form, please see Discharge Sampling Manual.

Hospital ID #: |____|____|____|____|

Sampling Performed by: (check only one) □ RTI Abstractor □ Hospital Staff □ NHDS Project Staff

Dates of Sampling Period: Start date: ___/___/___ End date: ___/___/___ Number of Months in Sampling Period: _____

Date Sampling Performed: |____|____| - |____|____| - |____|____| Name of person performing sampling: ________________________

MM DD YY

TABLE I

	a. Did the hospital serve this group of patients during 2008?	b. Total Number of Discharges in this group during this sampling period (zero if ‘No’ to a.)	c. Number of cases targeted for sampling in this sampling period	d. Sampling Interval for this group ( b divided by c )	e. Number of cases actually sampled in this sampling period	f. Random start number
Group 1: Observation status cases	□ Yes □ No
Group 2: Normal Newborn Infants	□ Yes □ No
Group 3: Discharges with Acute Myocardial Infarction	□ Yes □ No
Group 4: In-Hospital Deaths	□ Yes □ No
Group 9: All other Inpatient Discharges	□ Yes □ No

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OMB No. 0920-0212: Approval Expires 10/31/2011

AMPLE LISTING SHEET

PART B: Information about Sampled Discharges

Hospital ID # |___|___|___|___|

Dates of Sampling Period: Start date: ___/___/___ End date: ___/___/___

Please use the following codes to indicate the group to which sampled cases belong

Group 1 = Observation status cases

Group 2 = Normal newborn infants

Group 3 = Discharges with acute myocardial infarction

Group 4 = In-hospital deaths

Group 9 = All other inpatient discharges

T TABLE II

Code for group Identifier	Sequence # on group listing for this sampling period	Date of discharge (MM/DD/YY)	Discharge identifier used by hospital	Alternate identifier, if needed	Date abstracted (or out-of-scope reason)	HDS #

CARRY-OVER NUMBER (to be used at next sampling period):

(Please see Discharge Sampling Manual for explanation of Carry-over Number.)

Group 1 _______ Group 2 _______ Group 3 _______ Group 4 _______ Group 5 _______

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OMB No. 0920-0212: Approval Expires 10/31/2011

OTES: Please provide any information that will help us understand your experience with the sampling process, including any questions, concerns or unusual circumstances you encountered (for example, difficulty assigning numbers to discharges; trouble creating listings for specified time periods; problems with forming groups of discharges according to specifications (i.e. using patient characteristics, medical diagnosis codes, etc); problems ordering discharges within lists by discharge dates) →