OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Pre-testing for 2019 Health Center Patient Survey (HCPS)

IC 236661 under ICR 201704-0915-001 · OMB 0915-0379.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 1E
Attachment 1E Patient Screening (English).docx Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 1S
Attachment 1S Patient Screening (Spanish).docx Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 2E
Attachment 2E Patient Screening Short Blessed Scale (English).docx Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 2S
Attachment 2S Patient Screening Short Blessed Scale (Spanish).DOC Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 2V
Attachment 2V Patient Screening Short Blessed Scale (Vietnamese).DOCX Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 2C
Attachment 2C Patient Screening Short Blessed Scale (Chinese).DOCX Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 2T
Attachment 2T Patient Screening Short Blessed Scale (Tagalog).DOCX Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 3E
Attachment 3E Patient Survey (English) 06.21.19.docx Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 3S
Attachment 3S Patient Survey (Spanish) 06.21.19.docx Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 3V
Attachment 3V Patient Survey (Vietnamese) 06.21.19.docx Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 3C
Attachment 3C Patient Survey (Chinese) 06.21.19.docx Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
Form 3T
Attachment 3T Patient Survey (Tagalog) 06.21.19.docx Pre-testing for 2019 Health Center Patient Survey (HCPS)		 Form and Instruction
1E Attachment 1E Patient Screening (English).docx
Attachment 7 Patient Screening (English).docx 		Form and Instruction
1S Attachment 1S Patient Screening (Spanish).docx
Attachment 7 Patient Screening (Spanish).docx 		Form and Instruction
2E Attachment 2E Patient Screening Short Blessed Scale (Eng
Attachment 9 Patient Screening Short Blessed Scale (English).docx 		Form and Instruction
2S Attachment 2S Patient Screening Short Blessed Scale (Spa
Attachment 9 Patient Screening Short Blessed Scale (Spanish).DOC 		Form and Instruction
2V Attachment 2V Patient Screening Short Blessed Scale (Vie
Attachment 9 Patient Screening Short Blessed Scale (Vietnamese).DOCX 		Form and Instruction
2C Attachment 2C Patient Screening Short Blessed Scale (Chi
Attachment 9 Patient Screening Short Blessed Scale (Chinese).DOCX 		Form and Instruction
2T Attachment 2T Patient Screening Short Blessed Scale (Tag
Attachment 9 Patient Screening Short Blessed Scale (Tagalog).DOCX 		Form and Instruction
3E Attachment 3E Patient Survey (English) 06.21.19.docx
Attachment 1 Patient Survey (English) 06.21.19.docx 		Form and Instruction
3S Attachment 3S Patient Survey (Spanish) 06.21.19.docx
Attachment 1 Patient Survey (Spanish) 06.21.19.docx 		Form and Instruction
3V Attachment 3V Patient Survey (Vietnamese) 06.21.19.docx
Attachment 1 Patient Survey (Vietnamese) 06.21.19.docx 		Form and Instruction
3C Attachment 3C Patient Survey (Chinese) 06.21.19.docx
Attachment 1 Patient Survey (Chinese) 06.21.19.docx 		Form and Instruction
3T Attachment 3T Patient Survey (Tagalog) 06.21.19.docx
Attachment 1 Patient Survey (Tagalog) 06.21.19.docx 		Form and Instruction
0379 - HCPS Supporting Statement A 06.21.19.docx
0379 - HCPS Supporting Statement A 06.21.19		IC Document
0379 - HCPS Supporting Statement B 06.21.19.docx
0379 - HCPS Supporting Statement B 06.21.19		IC Document
2019 Critical Incident Protocol_Inside&Outide Site.docx
2019 Critical Incident Protocol_Inside&Outide Site		IC Document
2019 HCPS Additions and Modifications.xlsx
2019 HCPS Additions and Modifications		IC Document
2019 Respondent Resources List.docx
2019 HCPS Additions and Modifications		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1E Yes Yes Fillable Fileable
Form and Instruction 1S Yes Yes Fillable Fileable
Form and Instruction 2E Yes Yes Fillable Fileable
Form and Instruction 2S Yes Yes Fillable Fileable
Form and Instruction 2V Yes Yes Fillable Fileable
Form and Instruction 2C Yes Yes Fillable Fileable
Form and Instruction 2T Yes Yes Fillable Fileable
Form and Instruction 3E Yes Yes Fillable Fileable
Form and Instruction 3S Yes Yes Fillable Fileable
Form and Instruction 3V Yes Yes Fillable Fileable
Form and Instruction 3C Yes Yes Fillable Fileable
Form and Instruction 3T Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 88 0 88 0 0 0
Annual IC Time Burden (Hours) 77 0 77 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
0379 - HCPS Supporting Statement A 06.21.19 06/25/2019
0379 - HCPS Supporting Statement B 06.21.19 06/25/2019
2019 Critical Incident Protocol_Inside&Outide Site 06/25/2019
2019 HCPS Additions and Modifications 06/25/2019
2019 HCPS Additions and Modifications 06/25/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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