Survey Instruments
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Note: In addition to NAMCS and NHAMCS data released on public use micro-data files, results from the survey supplements listed below may also be available in the NCHS Research Data Center (RDC). For example, data from the NAMCS Electronic Medical Record Supplement (2008-2011), the National Electronic Health Records Survey (2012-2015), and the 2008 NHAMCS Pandemic and Emergency Response Preparedness Supplement, are now available for use in the RDC. Please refer to NAMCS and NHAMCS Restricted Data Available at the NCHS Research Data Center [PDF - 53 KB] for more information, visit the RDC website or contact the Ambulatory and Hospital Care Statistics Branch at 301-458-4600.
NAMCS Survey Instruments
2017
2015
- Patient Record Sample Card [PDF - 181 KB]
- Physician Induction Interview Sample Card [PDF - 402 KB]
- National Electronic Health Records Survey [PDF - 213 KB]
2014
- Patient Record Sample Card [PDF – 105 KB]
- Physician Induction Interview Sample Card [PDF - 178 KB]
- National Electronic Health Records Survey – Long Form [PDF - 295 KB]
- National Electronic Health Records Survey – Short Form [PDF - 134 KB]
2013
- Patient Record Sample Card [PDF – 95 KB]
- Physician Induction Interview Sample Card [PDF - 285 KB]
- Lookback Module [PDF - 75 KB]
- National Electronic Health Records Survey [PDF - 172 KB]
- Physician Workflow Supplement for EHR Adopters [PDF - 105 KB]
- Physician Workflow Supplement for EHR Non-Adopters [PDF - 106 KB]
2012
- Patient Record Sample Card [PDF – 95 KB]
- Physician Induction Interview Sample Card [PDF - 288 KB]
- Lookback Module [PDF - 75 KB]
- National Electronic Health Records Survey [PDF - 189]
- Physician Workflow Supplement for EHR Adopters [PDF - 389 KB]
- Physician Workflow Supplement for EHR Non-Adopters [PDF - 386 KB]
- Asthma Supplement [PDF – 137 KB]
2011
- Patient Record Form [PDF - 129 KB]
- Physician Induction Interview Form [PDF - 303 KB]
- Community Health Center Induction Interview Form [PDF -222 KB]
- Electronic Medical Records Supplement [PDF - 74 KB]
- Physician Workflow Supplement for EHR Non-Adopters [PDF - 116 KB]
- Physician Workflow Supplement for EHR Adopters [ PDF 199 KB]
2010
- Patient Record Form A [PDF - 140 KB]
- Patient Record Form B [PDF - 125 KB] (contains additional questions on lab values on the reverse side, completed only by certain physician specialties)
- Cervical Cancer Screening Supplement [PDF - 132 KB]
- Physician Induction Interview Form [PDF - 354 KB]
- Community Health Center Induction Interview Form [PDF - 194 KB]
- Electronic Medical Records Supplement [PDF - 91 KB]
2009
- Patient Record Form [PDF - 129 KB]
- Cervical Cancer Screening Supplement [PDF - 147 KB]
- Physician Induction Interview Form [PDF - 518 KB]
- Community Health Center Induction Interview Form [PDF - 235 KB]
- Electronic Medical Records Supplement [PDF - 72 KB]
2008
- Patient Record Form [PDF - 246 KB]
- Cervical Cancer Screening Supplement [PDF - 406 KB]
- Physician Induction Interview Form [PDF - 2 MB]
- Community Health Center Induction Interview Form [PDF - 703 KB]
- Electronic Medical Records Supplement [PDF - 346 KB]
2007
- Patient Record Form [PDF - 94 KB]
- Cervical Cancer Screening Supplement [PDF - 123 KB]
- Physician Induction Interview Form [PDF - 400 KB]
- Community Health Center Induction Interview Form [PDF - 402 KB]
2006
- Patient Record Form [PDF - 104 KB]
- Cervical Cancer Screening Supplement[PDF - 259 KB]
- Physician Induction Interview Form [PDF - 1 MB]
- Community Health Center Induction Interview Form [PDF - 435 KB]
2005
2004
2003
2002
2001
1999-2000
1997-1998
1995-1996
NHAMCS Survey Instruments
2017
- Emergency Department Patient Record Sample Card [PDF - 108 KB]
- Outpatient Department Patient Record Sample Card [PDF - 165 KB]
- Ambulatory Surgery Patient Record Sample Card [PDF - 110 KB]
- Hospital Induction Interview Form [PDF – 251 KB]
2016
- Emergency Department Patient Record Sample Card [PDF - 76 KB]
- Outpatient Department Patient Record Sample Card [PDF - 130 KB]
- Ambulatory Surgery Patient Record Sample Card [PDF - 64 KB]
- Hospital Induction Interview Form [PDF – 424 KB]
2015
- Emergency Department Patient Record Sample Card [PDF - 77 KB]
- Outpatient Department Patient Record Sample Card [PDF - 195 KB]
- Ambulatory Surgery Patient Record Sample Card [PDF - 100 KB]
- Hospital Induction Interview Form [PDF – 420 KB]
2014
- Emergency Department Patient Record Sample Card [PDF - 109 KB]
- Outpatient Department Patient Record Sample Card [PDF - 104 KB]
- Ambulatory Surgery Patient Record Sample Card [PDF - 65 KB]
- Hospital Induction Interview Form [PDF – 146 KB]
2013
- Emergency Department Patient Record Sample Card [PDF - 101 KB]
- Outpatient Department Patient Record Sample Card [PDF - 98 KB]
- Ambulatory Surgery Patient Record Sample Card [PDF - 65 KB]
- Lookback Module Sample Card [PDF – 73 KB]
- Hospital Induction Interview Form [PDF – 477 KB]
2012
- Emergency Department Patient Record Sample Card [PDF - 112 KB]
- Outpatient Department Patient Record Sample Card [PDF - 60 KB]
- Ambulatory Surgery Patient Record Sample Card [PDF - 103 KB]
- Hospital Induction Interview Form [PDF – 560 KB]
2011
- Emergency Department Patient Record Form [PDF - 118 KB]
- Outpatient Department Patient Record Form [PDF - 140 KB]
- Ambulatory Surgery Center Patient Record Form [PDF - 125 KB]
- Hospital Induction Interview Form [PDF – 4.8 MB]
- Freestanding Ambulatory Surgery Center Induction Interview Form [PDF – 299 KB]
- Ambulatory Unit Induction Interview Form [PDF - 104 KB]
2010
- Emergency Department Patient Record Form [PDF - 103 KB]
- Outpatient Department Patient Record Form [PDF - 123 KB]
- Ambulatory Surgery Center Patient Record [PDF - 110 KB]
- Cervical Cancer Screening Supplement [PDF - 138 KB]
- Hospital Induction Interview Form [PDF - 359 KB]
- Freestanding Ambulatory Surgery Center Induction Interview Form [PDF – 263 KB]
- Ambulatory Unit Induction Interview Form [PDF - 110 KB]
2009
- Emergency Department Patient Record Form [PDF - 114 KB]
- Outpatient Department Patient Record Form [PDF - 168 KB]
- Ambulatory Surgery Center Patient Record [PDF - 132 KB]
- Cervical Cancer Screening Supplement [PDF - 150 KB]
- Hospital Induction Interview Form [PDF - 558 KB]
- Ambulatory Unit Induction Interview Form [PDF - 186 KB]
2008
- Emergency Department Patient Record Form [PDF - 208 KB]
- Outpatient Department Patient Record Form [PDF - 453 KB]
- Cervical Cancer Screening Supplement [PDF - 189 KB]
- Hospital Induction Interview Form [PDF - 1277 KB]
- Ambulatory Unit Induction Interview Form [PDF - 129 KB]
- Pandemic and Emergency Response Preparedness Supplement [PDF - 119 KB]
2007
- Emergency Department Patient Record Form [PDF - 439 KB]
- Outpatient Department Patient Record Form [PDF - 146 KB]
- Cervical Cancer Screening Supplement [PDF - 107 KB]
- Hospital Induction Interview Form [PDF - 331 KB]
- Ambulatory Unit Induction Interview Form [PDF - 122 KB]
2006
- Emergency Department Patient Record Form [PDF - 58 KB]
- Outpatient Department Patient Record Form [PDF - 51 KB]
- Emergency Pediatric Services and Equipment Supplement [PDF - 228 KB]
- Cervical Cancer Screening Supplement [PDF - 54 KB]
- Hospital Induction Interview Form [PDF - 126 KB]
- Ambulatory Unit Induction Interview Form [PDF - 54 KB]
2005
- Emergency Department Patient Record Form [PDF - 66 KB]
- Outpatient Department Patient Record Form [PDF - 58 KB]
- Hospital Induction Interview Form [PDF - 126 KB]
- Ambulatory Unit Induction Interview Form [PDF - 54 KB]
2004
- Emergency Department Patient Record Form [PDF - 158 KB]
- Outpatient Department Patient Record Form [PDF - 361 KB]
2003
- Emergency Department Patient Record Form [PDF - 383 KB]
- Outpatient Department Patient Record Form [PDF - 312 KB]
2002
- Emergency Department Patient Record Form [PDF - 1.5 MB]
- Outpatient Department Patient Record Form [PDF - 1 MB]
2001
- Emergency Department Patient Record Form [PDF - 259 KB]
- Outpatient Department Patient Record Form [PDF - 319 KB]
1999-2000
- Emergency Department Patient Record Form [PDF - 2 KB]
- Outpatient Department Patient Record Form [PDF - 2 KB]
1997-1998
- Emergency Department Patient Record Form [PDF - 205 KB]
- Outpatient Department Patient Record Form [PDF - 208 KB]
- Instructions for completing Patient Record Form [PDF - 51 KB]
1995-1996
- Page last reviewed: April 12, 2017
- Page last updated: April 12, 2017
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