Health Center Patient Survey

Forms and Documents

Document Name	Status
Form 1 Health Center Patient Survey Patient Screening Form Form	New
Form 1 Health Center Patient Survey Patient Survey Instrument Form and Instruction	New
Form 1 Patient Survey Instrument Form and Instruction	Removed
Form 1 Patient Screening Form Form	Removed
USC Title 42 Section 254b.pdf Supplementary Document	2014-05-14
Technical Advisory Committee Members.pdf Supplementary Document	2014-05-14
Survey Methodology and Selection Specifications.pdf Supplementary Document	2014-05-14
Statistical Design Plan.pdf Supplementary Document	2014-05-14
Definition of Final Stratification.pdf Supplementary Document	2014-05-14
Data Security Plan.pdf Supplementary Document	2014-05-14
Attachment 5 Informed Consent and Other Procedural Forms.pdf Supplementary Document	2014-05-14
Attachment 5 Consent Forms Vietnamese.pdf Supplementary Document	2014-05-14
Attachment 5 Consent Forms Spanish.pdf Supplementary Document	2014-05-14
Attachment 5 Consent Forms Korean.pdf Supplementary Document	2014-05-14
Attachment 5 Consent Forms Chinese.pdf Supplementary Document	2014-05-14
Attachment 4 Introductory and Recruitment Materials for Patients Vietnamese.pdf Supplementary Document	2014-05-14
Attachment 4 Introductory and Recruitment Materials for Patients Spanish.pdf Supplementary Document	2014-05-14
Attachment 4 Introductory and Recruitment Materials for Patients Korean .pdf Supplementary Document	2014-05-14
Attachment 4 Introductory and Recruitment Materials for Patients Chinese.pdf Supplementary Document	2014-05-14
Attachment 4 Grantee Site Recruitment Materials.pdf Supplementary Document	2014-05-14
Attachment 2 HCPS Instrument Vietnamese.pdf Supplementary Document	2014-05-14
Attachment 2 HCPS Instrument Spanish.pdf Supplementary Document	2014-05-14
Attachment 2 HCPS Instrument Chinese.pdf Supplementary Document	2014-05-14
Attachment 2 HCPS Instrument Korean.pdf Supplementary Document	2014-05-14
Attachment 3 Results of Pretest.pdf Supplementary Document	2014-05-14
Supporting Statement A 0368.docx Supporting Statement A	2014-07-07
Supporting Statement B.docx Supporting Statement B	2014-05-14
Appendix E Critical Incident Form.docx Supplementary Document	2013-04-30
Appendix D Data Security Plan.docx Supplementary Document	2013-04-30
Appendix B 60Day Federal Notice.pdf Supplementary Document	2013-04-30
Appendix C Technical Advisory Committee Members.docx Supplementary Document	2013-04-30
Appendix A - 2006 USC Title 42 Section 254b.pdf Supplementary Document	2013-04-30
OMB_Vietnamese_materials.pdf Supplementary Document	2013-04-30
OMB_Spanish_materials.pdf Supplementary Document	2013-04-30
OMB_Chinese_Materials.pdf Supplementary Document	2013-04-30
OMB_Korean_materials.pdf Supplementary Document	2013-04-30
Incentive Receipt.doc Supplementary Document	2013-05-09
Consent forms (3).doc Supplementary Document	2013-05-09
2014 Health Center Patient Survey Cognitive Protocol Intro.doc Supplementary Document	2013-05-09
Handout_English.doc Supplementary Document	2013-05-09
Flyer.doc Supplementary Document	2013-05-09
Recruitment Script_At Clinic.docx Supplementary Document	2013-05-09

IC Document Collections

IC ID	Document Title	Status
211603	Health Center Patient Survey Patient Screening Form Form	New
211602	Health Center Patient Survey Patient Survey Instrument Form and Instruction	New
206893	Patient Survey Instrument Form and Instruction	Removed
206892	Patient Screening Form Form	Removed

ICR Details

OMB Control No: 0915-0368	ICR Reference No: 201404-0915-008
Status: Historical Active	Previous ICR Reference No: 201305-0915-003
Agency/Subagency: HHS/HSA	Agency Tracking No: 19425
Title: Health Center Patient Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/14/2014
	Date Received in OIRA: 05/27/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2017	36 Months From Approved	09/30/2016
Responses	13,596	0	161
Time Burden (Hours)	9,439	0	95
Cost Burden (Dollars)	0	0	0

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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. The 2014 Health Center Patient Survey (herein referred to as the HCPS) will collect nationally in-depth information about Section 330-funded health center patients, their health status, the reasons they seek care at the health centers, their diagnoses, the services they utilize at HCs and elsewhere, the quality of those services, and their satisfaction with the care they receive, through personal interviews of a stratified random sample of HC patients. Interviews conducted in the national study are estimated to take approximately 1 hour and 15 minutes each.

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Authorizing Statute(s): US Code: 42 USC 330-331 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:
	78 FR 2411	01/11/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 25598	05/05/2014
Did the Agency receive public comments on this ICR? No

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

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

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ICR Summary 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	13,596	161	0	13,435	0	0
Annual Time Burden (Hours)	9,439	95	0	9,344	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This is a revision to a new information collection. The first approval was for pretesting. This request is for the full survey.

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Annual Cost to Federal Government: $2,656,396

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]? 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

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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: 05/27/2014

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