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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Annual Hospital Interview
Modified
581
1162
0
Form and Instruction
0920-0212
Att J - Proposed Final Annual Hospital Interview
Annual Ambulatory Hospital Interview
Modified
385
578
0
Form and Instruction
0920-0212
Att K - Ann Amb Hosp Inter
Annual FSASC Interview
Removed
0
0
0
Form
none
Annual FSASC Interview
FSASC Prepare and Transmit UB-40
Removed
0
0
0
Instruction
FSASC Pulling and Refiling Patient Records
Removed
0
0
0
Instruction
Initial Hospital Intake Questionnaire
Modified
160
160
0
Form and Instruction
0920-0212
Att N - Proposed Final Initial Hosp Intake Ques
Prepare and Transmit EHR for Inpatient and Ambulatory
Modified
400
400
0
Form and Instruction
0920-0212
Att W - Qtr Data Trans of EHR Data
Prepare and transmit UB-04 or State File for Inpatient and Ambulatory
Modified
5772
5772
0
Form and Instruction
0920-0212
Att P - Mth Data Trans of UB-04 Data
Pulling and re-filing Patient Records (ED, OPD, and ASL)
Removed
0
0
0
Instruction
Recruitment Survey Presentation
Modified
160
160
0
Form and Instruction
0920-0212
Att O - Recruitment Survey Pres
Total burden requested under this ICR:
7458
8232
0
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