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  
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