Pretests

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⚠️ Notice: This information collection may be referencing outdated material.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
Pretests Form
Ambulatory Unit Induction pretest Attachment C - NHAMCS-101(U).pdf Form
Freestanding Ambulatory Surgery Center Induction pretest Attachment B - NHAMCS-101FS.pdf Form
Asthma Management Supplement pretest Attachment D - NHAMCS-908 Asthma Supplement-revised.pdf Form
Hospital Induction pretest Attachment A - NHAMCS-101.pdf Form
Outpatient Dept Patient Record pretest Attachment E - NHAMCS-100(OPD) -rev.pdf Form
Ambulatory Surgery Center Patient Record pretest Attachment F - NHAMCS-100(ASC)-revised.pdf Form
Emergency Dept Patient Record pretest Attachment G - NHAMCS-100(ED)-revised.pdf Form
Lookback Module pretest Attachment H - NHAMCS-910 Lookback Module-revised.pdf Form
Pulling and Refiling Records pretest Attachment I - Pulling records.doc Form

Information Collection (IC) Details

IC Title:	Pretests	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Outpatient Dept Patient Record pretest	Attachment E - NHAMCS-100(OPD) -rev.pdf	No	No	Paper Only
Form	none	Ambulatory Surgery Center Patient Record pretest	Attachment F - NHAMCS-100(ASC)-revised.pdf	No	No	Paper Only
Form	none	Emergency Dept Patient Record pretest	Attachment G - NHAMCS-100(ED)-revised.pdf	No	No	Paper Only
Form	none	Lookback Module pretest	Attachment H - NHAMCS-910 Lookback Module-revised.pdf	No	No	Paper Only
Form	none	Pulling and Refiling Records pretest	Attachment I - Pulling records.doc	No	No	Paper Only
Form	none	Ambulatory Unit Induction pretest	Attachment C - NHAMCS-101(U).pdf	No	No	Paper Only
Form	none	Freestanding Ambulatory Surgery Center Induction pretest	Attachment B - NHAMCS-101FS.pdf	No	No	Paper Only
Form	none	Asthma Management Supplement pretest	Attachment D - NHAMCS-908 Asthma Supplement-revised.pdf	No	No	Paper Only
Form	none	Hospital Induction pretest	Attachment A - NHAMCS-101.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: Health Resources Utilization Statistics	FR Citation: 49 FR 37693

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,028	1,028
Annual IC Time Burden (Hours)	82	82
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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