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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Ambulatory Unit Induction
Modified
2000
500
0
Form
none
Ambulatory Unit Induction
Annual Ambulatory Hospital Interview
Modified
500
750
0
Form
none
Annual Ambulatory Hospital Interview
Annual FSASC Interview
New
250
125
0
Form
none
Annual FSASC Interview
Annual Inpatient Hospital Interview
Modified
500
500
0
Form
none
Annual Inpatient Hospital Interview
FSASC Prepare and Transmit UB-40
New
1000
1000
0
Instruction
FSASC Pulling and Refiling Patient Records
New
12500
208
0
Instruction
Initial Hospital Intake Questionnaire
Modified
133
133
0
Form
none
Initial Hospital Intake
Prepare and transmit UB-04 for Inpatient and Ambulatory
Modified
2000
2000
0
Form
none
Quarterly Transmission of UB-04 Data
Pulling and re-filing Patient Records (ED, OPD, and ASL)
New
112500
1875
0
Instruction
Recruitment Survey Presentation
Modified
133
133
0
Form
none
Recruitment Survey Presentation
Total burden requested under this ICR:
131516
7224
0
To view an IC, click on IC Title