Information Collection Request

Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration (HRSA)

ICR 201704-0915-001 · OMB 0915-0379 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 3T Attachment 3T Patient Survey (Tagalog) 06.21.19.docx Form and Instruction New Available
Form 3C Attachment 3C Patient Survey (Chinese) 06.21.19.docx Form and Instruction New Available
Form 3V Attachment 3V Patient Survey (Vietnamese) 06.21.19.docx Form and Instruction New Available
Form 3S Attachment 3S Patient Survey (Spanish) 06.21.19.docx Form and Instruction New Available
Form 3E Attachment 3E Patient Survey (English) 06.21.19.docx Form and Instruction New Available
Form 2T Attachment 2T Patient Screening Short Blessed Scale (Tagalog).DOCX Form and Instruction New Available
Form 2C Attachment 2C Patient Screening Short Blessed Scale (Chinese).DOCX Form and Instruction New Available
Form 2V Attachment 2V Patient Screening Short Blessed Scale (Vietnamese).DOCX Form and Instruction New Available
Form 2S Attachment 2S Patient Screening Short Blessed Scale (Spanish).DOC Form and Instruction New Source copy available
Form 2E Attachment 2E Patient Screening Short Blessed Scale (English).docx Form and Instruction New Available
Form 1S Attachment 1S Patient Screening (Spanish).docx Form and Instruction New Available
Form 1E Attachment 1E Patient Screening (English).docx Form and Instruction New Available
Form 20 2018 MCH Survey Juris Module_USVI_Spanish_Formatted.docx Form New Available
Form 19 2018 MCH Survey Juris Module_PR_Spanish_Formatted.docx Form New Available
Form 18 2018 MCH Survey Core_USVIandPR_Spanish_Formatted.doc Form New Available
Form 17 2018 MCH Survey Juris Module_Palau_Tagalog_Formatted.docx Form New Available
Form 16 2018 MCH Survey Core_Palau_Tagalog_Formatted.doc Form New Available
Form 15 2018 MCH Survey Juris Module_Palau_Palauan_Formatted.docx Form New Available
Form 14 2018 MCH Survey Core_Palau_Palauan_Formatted.doc Form New Available
Form 13 2018 MCH Survey Juris Module_MarshallIslands_Marshallese_Formatted.doc Form New Available
Form 12 2018 MCH Survey Core_MarshallIslands_Marshallese_Formatted.doc Form New Available
Form 11 2018 MCH Survey Juris Module_AS_Samoan_Formatted.doc Form New Available
Form 10 2018 MCH Survey Core_AS_Samoan_Formatted.doc Form New Available
Form 9 2018 MCH Survey Juris Module_USVI_English_Formatted.doc Form New Available
Form 8 2018 MCH Survey Juris Module_PR_English_Formatted.doc Form New Available
Form 7 2018 MCH Survey Juris Module_Palau_English_Formatted.doc Form New Available
Form 6 2018 MCH Survey Juris Module_MarshallIslands_English_Formatted.doc Form New Available
Form 5 2018 MCH Survey Juris Module_Guam_English_Formatted.doc Form New Available
Form 4 2018 MCH Survey Juris Module_FSM_English_Formatted.doc Form New Available
Form 3 2018 MCH Survey Juris Module_CNMI_English_Formatted.doc Form New Available
Form 2 2018 MCH Survey Juris Module_AS_English_Formatted.doc Form New Available
Form 1 2018 MCH Survey Core_English_Formatted FINAL.docx Form New Available
Template for Generic Pretesting Package Supporting Statement A.docx Supplementary Document Uploaded 2017-06-06 Available
Supporting Statement B.docx Supporting Statement B Uploaded 2017-04-04 Available
FINALSupporting Statement A Revised 6-2-17.docx Supporting Statement A Uploaded 2017-06-02 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 3T Patient Survey (Tagalog) 06.21.19.docx
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 3C Patient Survey (Chinese) 06.21.19.docx
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 3V Patient Survey (Vietnamese) 06.21.19.docx
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 3S Patient Survey (Spanish) 06.21.19.docx
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 3E Patient Survey (English) 06.21.19.docx
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 2T Patient Screening Short Blessed Scale (Tagalog).DOCX
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 2C Patient Screening Short Blessed Scale (Chinese).DOCX
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 2V Patient Screening Short Blessed Scale (Vietnamese).DOCX
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 2S Patient Screening Short Blessed Scale (Spanish).DOC
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 2E Patient Screening Short Blessed Scale (English).docx
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 1S Patient Screening (Spanish).docx
236661 Pre-testing for 2019 Health Center Patient Survey (HCPS) Form and Instruction NewAttachment 1E Patient Screening (English).docx
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_USVI_Spanish_Formatted.docx
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_PR_Spanish_Formatted.docx
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Core_USVIandPR_Spanish_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_Palau_Tagalog_Formatted.docx
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Core_Palau_Tagalog_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_Palau_Palauan_Formatted.docx
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Core_Palau_Palauan_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_MarshallIslands_Marshallese_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Core_MarshallIslands_Marshallese_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_AS_Samoan_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Core_AS_Samoan_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_USVI_English_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_PR_English_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_Palau_English_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_MarshallIslands_English_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_Guam_English_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_FSM_English_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_CNMI_English_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Juris Module_AS_English_Formatted.doc
232178 Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument Form New2018 MCH Survey Core_English_Formatted FINAL.docx

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
06/30/2020 36 Months From Approved 06/30/2017
5,225 0 15,000
3,200 0 13,333
0 0 0





Reginfo record details
2
table that charts list of burden
IC Title Form No. Form Name
Pre-testing for 2019 Health Center Patient Survey (HCPS) 2V, 1S, 2S, 2T, 3E, 3S, 3V, 2C, 1E, 2E, 3C, 3T ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,  
Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 9 ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,  

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 5,225 15,000 0 -9,775 0 0
Annual Time Burden (Hours) 3,200 13,333 0 -10,133 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No