Bureau of Primary Health Care Patient Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 001-BPHC Patient S Bureau of Primary Health Care Patient Survey	Form	New	Available
UpdatedMaterials.pdf	Supplementary Document	Uploaded 2009-07-08	Available
Questionnaire_V6_06222009.pdf	Supplementary Document	Uploaded 2009-07-08	Available
HRSA Response to OMB Comments_Final.pdf	Supplementary Document	Uploaded 2009-07-08	Available
Cognitive_Interview _Report_1st round _2_.pdf	Supplementary Document	Uploaded 2009-07-08	Available
Cognitive Interview Report_2nd round _2_.pdf	Supplementary Document	Uploaded 2009-07-08	Available
Approval Notice.11947.Renewal.2009.pdf	Supplementary Document	Uploaded 2009-07-08	Available
ss_BPHC Patient Survey - NEW - PART B.pdf	Supporting Statement B	Uploaded 2009-03-04	Available
Attachment 11 - Approval Notice.11947.Amend.02-06-09.pdf	Supplementary Document	Uploaded 2009-03-03	Available
Attachment 10 - Survey Methodology and Selection Specifications.pdf	Supplementary Document	Uploaded 2009-03-03	Available
Attachment 9 - Definition of Final Stratification.pdf	Supplementary Document	Uploaded 2009-03-03	Available
Attachment 8 - Statistical Design Plan.pdf	Supplementary Document	Uploaded 2009-03-03	Available
Attachment 7 - Data Security Plan.pdf	Supplementary Document	Uploaded 2009-03-03	Available
Attachment 6 - Technical Advisory Panel.pdf	Supplementary Document	Uploaded 2009-03-03	Available
Attachment 5 - Informed Consent Forms.pdf	Supplementary Document	Uploaded 2009-03-03	Available
Attachment 4 - Letters and Materials for grantees, sites and patients.pdf	Supplementary Document	Uploaded 2009-03-03	Available
Attachment 3 - Data elements for the survey instrument.pdf	Supplementary Document	Uploaded 2009-03-03	Available
Attachment 2 - Survey Instrument - 02-12-09.pdf	Supplementary Document	Uploaded 2009-03-03	Available
Attachment 1 - 2006 USC Title 42 Section 254b.pdf	Supplementary Document	Uploaded 2009-03-03	Available
ss_BPHC Patient Survey - NEW - PART A.pdf	Supporting Statement A	Uploaded 2009-03-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
188365	Bureau of Primary Health Care Patient Survey	Form	New

ICR Details

OMB Control No: 0915-0326	ICR Reference No: 200903-0915-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Bureau of Primary Health Care Patient Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/14/2009
	Date Received in OIRA: 03/10/2009
Terms of Clearance: This ICR is approved consistent with revised instruments and responses to passback. Per AHRQ memo of July 7, 2009, AHRQ agrees to explicitly acknowledge, as one of the limitations of this study and in all public disclosures of the study results, that the sampling approach in this study does not provide for a true probability sample .

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2011	18 Months From Approved
Responses	5,773	0	0
Time Burden (Hours)	7,218	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Health centers improve the health of the Nation's underserved communities and vulnerable populations by assuring access to comprehensive, culturally competent, quality primary health care services. The survey will include a sample of patients from all four types of section 330-funded health center programs. Specifically, the survey will collect in-depth information about health center patients such as their health status, the reasons they seek care at health centers, their diagnoses, the services they utilize at health centers and elsewhere, the quality of those services, and their satisfaction with the care they receive.

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Authorizing Statute(s): US Code: 42 USC 254b Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 75120	12/10/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 9251	03/03/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Bureau of Primary Health Care Patient Survey	001-BPHC Patient Survey	BPHC Patient Survey Instrument

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	5,773	0	0	5,773	0	0
Annual Time Burden (Hours)	7,218	0	0	7,218	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new activity, the burden for the activity is in accordance with previous surveys conducted in 1995 and 2003.

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Annual Cost to Federal Government: $3,843,721

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/10/2009

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