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
Annual Ambulatory Hospital Interview Modified 385 578 0 Form and Instruction 0920-0212
Annual FSASC Interview Removed 0 0 0 Form none
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
Prepare and Transmit EHR for Inpatient and Ambulatory Modified 400 400 0 Form and Instruction 0920-0212
Prepare and transmit UB-04 or State File for Inpatient and Ambulatory Modified 5772 5772 0 Form and Instruction 0920-0212
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
Total burden requested under this ICR: 7458 8232 0  
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