View Information Collection (IC)

View Information Collection (IC)

IC Title:	Prepare and Submit EHR for Inpatient and Ambulatory	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Instruction			Att W - Quarterly Data Trans of EHR Data.doc		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0167 Health Resources Utilization Statistics	FR Citation: 49 FR 37693

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	400	0	400	0	0	0
Annual IC Time Burden (Hours)	400	0	400	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
EHR Variables - Inpatient Discharges	Att G - List of Var for EHR Extract of IP Disch.docx	02/19/2015
EHR Variables - Emergency Dept	Att H - List of Var for EHR Extract of ED Visits.docx	02/19/2015
EHR Variables - Outpatient Dept	Att I - List of Var for EHR Extract of OPD Visits.docx	02/19/2015

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