National Hospital Ambulatory Medical Care Survey

OMB Control No: 0920-0278	ICR Reference No: 201106-0920-001
Status: Historical Inactive	Previous ICR Reference No: 201011-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Hospital Ambulatory Medical Care Survey
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 06/08/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/01/2011
Terms of Clearance: Please resubmit with burden errors corrected. Total should be 20 facilities added and 82 hours of burden

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2012	08/31/2012	08/31/2012
Responses	128,141	0	128,141
Time Burden (Hours)	12,112	0	12,112
Cost Burden (Dollars)	0	0	0

---

Abstract: This request is to conduct pretests for the automation of the 2012 National Hospital Ambulatory Medical Care Survey (NHAMCS) and to test an asthma supplement.

---

Authorizing Statute(s): US Code: 42 USC 306 Name of Law: Public Health Service Act

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

IC Title Form No. Form Name Cervical Cancer Screening Supplement unnumbered Att. T. Cervical Cancer Screening Supplement Ambulatory Unit Record unnumbered, none Att. J. Ambulatory Unit Induction Form ,   Att. J. Ambulatory Unit Induction Form - 11/29/2010 Hospital Induction Form none, none Hospital Induction Form ,   Hospital Induction Form - 11/29/2010 ED Patient Record Form unnumbered Att. M. ED Patient Record Form ASC Patient Record Form unnumbered Att. O. ASC Patient Record Form OPD Patient Record Form none, none OPD Patient Record ,   OPD Patient Record - 11/29/2010 Pulling and re-filing Patient Records Freestanding ASC Induction Form none, none Freestanding Ambulatory Surgery Centers Form ,   Freestanding Ambulatory Surgery Centers Form - 11/29/2010 Pretests none, none, none, none, none, none, none, none, none Outpatient Dept Patient Record pretest ,   Ambulatory Surgery Center Patient Record pretest ,   Emergency Dept Patient Record pretest ,   Lookback Module pretest ,   Pulling and Refiling Records pretest ,   Ambulatory Unit Induction pretest ,   Freestanding Ambulatory Surgery Center Induction pretest ,   Asthma Management Supplement pretest ,   Hospital Induction pretest

---

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $4,473,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Daniel Holcomb 770 488-4472 [email protected]

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(i) Why the information is being collected;
			(ii) Use of information;
			(iii) Burden estimate;
			(iv) Nature of response (voluntary, required for a benefit, or mandatory);
			(v) Nature and extent of confidentiality; and
			(vi) Need to display currently valid OMB control number;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date: 06/01/2011

---