Hospital Data Abstraction Form

Hospital Data Abstraction Form, Evaluation of Emergency Department Crisis Center Follow-up

Documents and Forms

Document Name Document Type
Form Hospital Data Abst Hospital Data Abstraction Form Form and Instruction
Hospital Data Abst Hospital Data Abstraction Form Attachment A_Hospital Data Abstraction Form.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Hospital Data Abstraction 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	Hospital Data Abstraction Form	Hospital Data Abstraction Form	Attachment A_Hospital Data Abstraction Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,011	9,344	667
Annual IC Time Burden (Hours)	401	374	27
Annual IC Cost Burden (Dollars)	0	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.