Information Collection

ED Patient Record Form

IC 181865 under ICR 201007-0920-004 · OMB 0920-0278.

⚠️ Notice: This information collection may be referencing outdated material.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 unnumbered ED Patient Record Form Form
unnumbered Att. M. ED Patient Record Form NHAMCS2010 Attachment M - NHAMCS-100(ED).pdf Form
NHAMCS2010 Attachment Q - NHAMCS-122.pdf Att. Q. Emergency Dept. Instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ED 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	unnumbered	Att. M. ED Patient Record Form	NHAMCS2010 Attachment M - NHAMCS-100(ED).pdf		Yes	Yes	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: 225	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	22,500	22,500
Annual IC Time Burden (Hours)	2,625	2,625
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att. Q. Emergency Dept. Instructions	NHAMCS2010 Attachment Q - NHAMCS-122.pdf	06/08/2009

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