Health Center Patient Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Patient Survey Instrument	Form and Instruction	New	Available
Form 1 Patient Screening Form	Form	New	Available
Supporting Statement B.docx	Supporting Statement B	Uploaded 2013-09-16	Repair queued
Appendix E Critical Incident Form.docx	Supplementary Document	Uploaded 2013-04-30	Available
Appendix D Data Security Plan.docx	Supplementary Document	Uploaded 2013-04-30	Available
Appendix B 60Day Federal Notice.pdf	Supplementary Document	Uploaded 2013-04-30	Available
Appendix C Technical Advisory Committee Members.docx	Supplementary Document	Uploaded 2013-04-30	Repair queued
Appendix A - 2006 USC Title 42 Section 254b.pdf	Supplementary Document	Uploaded 2013-04-30	Available
OMB_Vietnamese_materials.pdf	Supplementary Document	Uploaded 2013-04-30	Available
OMB_Spanish_materials.pdf	Supplementary Document	Uploaded 2013-04-30	Available
OMB_Chinese_Materials.pdf	Supplementary Document	Uploaded 2013-04-30	Available
OMB_Korean_materials.pdf	Supplementary Document	Uploaded 2013-04-30	Available
Incentive Receipt.doc	Supplementary Document	Uploaded 2013-05-09	Available
Consent forms (3).doc	Supplementary Document	Uploaded 2013-05-09	Available
2014 Health Center Patient Survey Cognitive Protocol Intro.doc	Supplementary Document	Uploaded 2013-05-09	Available
Handout_English.doc	Supplementary Document	Uploaded 2013-05-09	Available
Flyer.doc	Supplementary Document	Uploaded 2013-05-09	Available
Recruitment Script_At Clinic.docx	Supplementary Document	Uploaded 2013-05-09	Available
Supporting Statement A.docx	Supporting Statement A	Uploaded 2013-05-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206893	Patient Survey Instrument	Form and Instruction	New
206892	Patient Screening Form	Form	New

ICR Details

OMB Control No: 0915-0368	ICR Reference No: 201305-0915-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No: 19425
Title: Health Center 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: 09/17/2013
	Date Received in OIRA: 05/13/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved
Responses	161	0	0
Time Burden (Hours)	95	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Health Center Patient Survey will gather information that will assist policymakers assessment of how well HRSA supported health centers are able to meet health care needs and complement data that are not routinely collected from other HRSA data sources. The cognitive pre-test will refine and test the survey instrument, test the survey sampling methodologies and procedures before it is implemented nationally. The respondents are Health Center patients from different racial/ethnic backgrounds.

---

Authorizing Statute(s): US Code: 42 USC 330-331 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 2411	01/11/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 27240	05/09/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Patient Screening Form	1	Patient Screener
Patient Survey Instrument	1	Patient Survey

---

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	161	0	0	161	0	0
Annual Time Burden (Hours)	95	0	0	95	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 information collection

---

Annual Cost to Federal Government: $2,065,959

Does this IC contain surveys, censuses, or employ statistical methods? No

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 05/13/2013

---