Health Center Patient Survey (HCPS_

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 3 T Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx	Form	New	Available
Form 3 V Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx	Form	New	Available
Form 3 S Attachment 13 Short Blessed Scale (Spanish)_psg.docx	Form	New	Available
Form 3 C Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx	Form	New	Available
Form 3 Attachment 13 Short Blessed Scale Test_psg.docx	Form	New	Available
Form 2 Attachment10 National_Awardee and Site Recruitment Materials_3-23-20	Form	New	Available
Form 1 Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx	Form	New	Available
Form 12 Contact Summary Report Form Final_psg.docx	Form	Modified	Available
Form 11 V Assent form for Accompanied Adolescent VIE_09-27-2019_psg.docx	Form	Modified	Available
Form 11 S Assent Form for Accompanied Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx	Form	Modified	Available
Form 11 C Assent Form for Accompanied Adolescent Final_TChinese_09272019_clean_psg.docx	Form	Modified	Available
Form 11 Assent Form for Accompanied Adolescent reviewed Final_psg.docx	Form	Modified	Available
Form 10 C Parent or Guardian Permission form for Adolescent Final_TChinese_09272019_clean_psg.docx	Form	Modified	Available
Form 10 V Parent or Guardian Permission form for Adolescent Final VIE_09-27-2019_psg.docx	Form	Modified	Available
Form 10 T Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx	Form	Modified	Available
Form 10 S Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx	Form	Modified	Available
Form 10 Parent or Guardian Permission form for Accompanied Adolescent reviewed Final_psg.docx	Form	Modified	Available
Form 9 V Informed Consent Form for Parent or Guardian Proxy VIE_09-27-2019_psg.docx	Form	Modified	Available
Form 9 T Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx	Form	Modified	Available
Form 9 S Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_09-27-2019_psg.docx	Form	Modified	Available
Form 9 C Informed Consent Form for Parent or Guardian Proxy Final_TChinese_09272019_clean_psg.docx	Form	Modified	Available
Form 9 Informed Consent Form for Parent or Guardian Proxy reviewed Final_psg.docx	Form	Modified	Available
Form 8 V Informed Consent Form for Adult Survey Participation VIE_09-27-2019_psg.docx	Form	Modified	Available
Form 8 T _Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx	Form	Modified	Available
Form 8 S Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx	Form	Modified	Available
Form 8 C Informed Consent Form for Adult Survey Participation Final_TChinese_09272019_clean_psg.docx	Form	Modified	Available
Form 8 Informed Consent Form for Adult Survey Participation reviewed Final_psg.docx	Form	Modified	Available
Form 7 V Final HCPS Screener_Vietnamese_09302019_psg.docx	Form	Modified	Available
Form 7 T Final HCPS Screener_Spanish_09302019_psg.docx	Form	Modified	Available
Form 7 S Final HCPS Screener_Spanish_09302019_psg.docx	Form	Modified	Available
Form 7 C Final HCPS Screener_Chinese_09302019_psg.docx	Form	Modified	Available
Form 7 Final HCPS Screener_English_09302019_psg.docx	Form	Modified	Available
Form 6 National_Patient Arrival and Referral Tracking Form Final_psg.docx	Form	Modified	Available
Form 5 T Incentive Receipt Tagalog_psg.docx	Form	Modified	Available
Form 5 V Incentive Receipt_Vietnamese_psg.docx	Form	Modified	Available
Form 5 S Incentive Receipt_SPA_rev_psg.docx	Form	Modified	Available
Form 5 C Incentive Receipt_TChinese_psg.docx	Form	Modified	Available
Form 5 Incentive Receipt (English)_psg.docx	Form	Modified	Available
Form 4 T HCPS Questionnaire_Tagalog_09302019_psg.docx	Form	Modified	Available
Form 4 V Final HCPS Questionnaire_Vietnamese_09302019_psg.docx	Form	Modified	Available
Form 4 S Tracked Change Final HCPS Questionnaire_Spanish_09302019_psg.docx	Form	Modified	Repair queued
Form 4 S Final HCPS Questionnaire_Spanish_09302019_psg_clean.docx	Form	Modified	Available
Form 4 C Final HCPS Questionnaire_Chinese_09302019_psg.docx	Form	Modified	Available
Form 4 Final HCPS Questionnaire_English_09302019_psg.docx	Form	Modified	Available
Supporting Statement B HCPS Revised TC PB 2 3-20.docx	Supporting Statement B	Uploaded 2020-03-23	Available
Supporting Statement A HCPS Revised TC PB 3-20.docx	Supporting Statement A	Uploaded 2020-03-23	Available
Attachment 13 2019 Critical Incident Form.docx	Supplementary Document	Uploaded 2019-12-26	Available
Attachment 13 2019 Critical Incident Protocol_In&Out Site.docx	Supplementary Document	Uploaded 2019-12-26	Available
Attachment 13 2019 Resources List.docx	Supplementary Document	Uploaded 2019-12-26	Repair queued
Attachment 13 Iinterview Appointment Card English.doc	Supplementary Document	Uploaded 2019-12-26	Available
Attachment 13 2019 FI JobAid_Train Receptionists_final.docx	Supplementary Document	Uploaded 2019-12-26	Available
Attachment 9 Sampling Strata_final.docx	Supplementary Document	Uploaded 2019-12-26	Available
Attachment 8_Survey Methodology and Selection Specification.pdf	Supplementary Document	Uploaded 2019-12-26	Available
Attachment 7_Statistical Design Plan.pdf	Supplementary Document	Uploaded 2019-12-26	Available
Attachment 6 Analysis Plan Overview_2019_final.docx	Supplementary Document	Uploaded 2019-12-26	Available
Attachment 5 2019 RTI Staff Privacy Pledge.docx	Supplementary Document	Uploaded 2019-12-26	Available
Attachment 4 TAP_Member_List_2019.xlsx	Supplementary Document	Uploaded 2019-12-26	Available
Attachment 3 60_Day_FRN_published_2019.pdf	Supplementary Document	Uploaded 2019-12-26	Available
HCPS Round 2 Cognitive Interview Report.docx	Supplementary Document	Uploaded 2020-03-23	Repair queued
HCPS Round 1 Cognitive Interview Results_080819.docx	Supplementary Document	Uploaded 2020-03-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
239087	Patient Screening: Short Blessed Scale	Form	New	Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
239087	Patient Screening: Short Blessed Scale	Form	New	Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx
239087	Patient Screening: Short Blessed Scale	Form	New	Attachment 13 Short Blessed Scale (Spanish)_psg.docx
239087	Patient Screening: Short Blessed Scale	Form	New	Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx
239087	Patient Screening: Short Blessed Scale	Form	New	Attachment 13 Short Blessed Scale Test_psg.docx
239085	Site Recruitment and Training	Form	New	Attachment10 National_Awardee and Site Recruitment Materials_3-23-20
239084	Awardee Recruitment	Form	New	Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Contact Summary Report Form Final_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Assent form for Accompanied Adolescent VIE_09-27-2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Assent Form for Accompanied Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Assent Form for Accompanied Adolescent Final_TChinese_09272019_clean_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Assent Form for Accompanied Adolescent reviewed Final_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Parent or Guardian Permission form for Adolescent Final_TChinese_09272019_clean_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Parent or Guardian Permission form for Adolescent Final VIE_09-27-2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Parent or Guardian Permission form for Accompanied Adolescent reviewed Final_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Informed Consent Form for Parent or Guardian Proxy VIE_09-27-2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_09-27-2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Informed Consent Form for Parent or Guardian Proxy Final_TChinese_09272019_clean_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Informed Consent Form for Parent or Guardian Proxy reviewed Final_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Informed Consent Form for Adult Survey Participation VIE_09-27-2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Informed Consent Form for Adult Survey Participation Final_TChinese_09272019_clean_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Informed Consent Form for Adult Survey Participation reviewed Final_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Final HCPS Screener_Vietnamese_09302019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Final HCPS Screener_Spanish_09302019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Final HCPS Screener_Spanish_09302019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Final HCPS Screener_Chinese_09302019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Final HCPS Screener_English_09302019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	National_Patient Arrival and Referral Tracking Form Final_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Incentive Receipt Tagalog_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Incentive Receipt_Vietnamese_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Incentive Receipt_SPA_rev_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Incentive Receipt_TChinese_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Incentive Receipt (English)_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	HCPS Questionnaire_Tagalog_09302019_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Final HCPS Questionnaire_Vietnamese_09302019_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Final HCPS Questionnaire_Spanish_09302019_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Final HCPS Questionnaire_Spanish_09302019_psg_clean.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Final HCPS Questionnaire_Chinese_09302019_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Final HCPS Questionnaire_English_09302019_psg.docx

ICR Details

OMB Control No: 0915-0368	ICR Reference No: 201912-0915-001
Status: Historical Active	Previous ICR Reference No: 201404-0915-008
Agency/Subagency: HHS/HSA	Agency Tracking No: 19425
Title: Health Center Patient Survey (HCPS_
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/24/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/26/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	36 Months From Approved
Responses	23,058	0	0
Time Burden (Hours)	13,876	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The HCPS 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 respondents are health center patients. Interviews are estimated to take approximately 60 minutes.

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Authorizing Statute(s): US Code: 42 USC 330-331, 254b,d 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:
	84 FR 35863	07/24/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 65988	12/02/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Awardee Recruitment	1	Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx
Health Center Patient Survey Patient Screening Form	6, 7, 7 C, 7 S, 7 T, 7 V, 8, 8 C, 8 S, 8 T, 8 V, 9, 9 C, 9 S, 9 T, 9 V, 10, 11, 10 S, 10 T, 10 V, 10 C, 11 C, 11 S, 11 V, 12	National_Patient Arrival and Referral Tracking Form Final_psg.docx ,   Final HCPS Screener_English_09302019_psg.docx ,   Final HCPS Screener_Chinese_09302019_psg.docx ,   Final HCPS Screener_Spanish_09302019_psg.docx ,   Final HCPS Screener_Spanish_09302019_psg.docx ,   Final HCPS Screener_Vietnamese_09302019_psg.docx ,   Informed Consent Form for Adult Survey Participation reviewed Final_psg.docx ,   Informed Consent Form for Adult Survey Participation Final_TChinese_09272019_clean_psg.docx ,   Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx ,   _Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx ,   Informed Consent Form for Adult Survey Participation VIE_09-27-2019_psg.docx ,   Informed Consent Form for Parent or Guardian Proxy reviewed Final_psg.docx ,   Informed Consent Form for Parent or Guardian Proxy Final_TChinese_09272019_clean_psg.docx ,   Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_09-27-2019_psg.docx ,   Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx ,   Informed Consent Form for Parent or Guardian Proxy VIE_09-27-2019_psg.docx ,   Parent or Guardian Permission form for Accompanied Adolescent reviewed Final_psg.docx ,   Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx ,   Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx ,   Parent or Guardian Permission form for Adolescent Final VIE_09-27-2019_psg.docx ,   Parent or Guardian Permission form for Adolescent Final_TChinese_09272019_clean_psg.docx ,   Assent Form for Accompanied Adolescent reviewed Final_psg.docx ,   Assent Form for Accompanied Adolescent Final_TChinese_09272019_clean_psg.docx ,   Assent Form for Accompanied Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx ,   Assent form for Accompanied Adolescent VIE_09-27-2019_psg.docx ,   Contact Summary Report Form Final_psg.docx
Health Center Patient Survey Patient Survey Instrument	5 C, 4, 4 C, 4 S, 4 S Tracked Changes, 4 V, 4 T, 5, 5 S, 5 V, 5 T	Final HCPS Questionnaire_English_09302019_psg.docx ,   Final HCPS Questionnaire_Chinese_09302019_psg.docx ,   Final HCPS Questionnaire_Spanish_09302019_psg_clean.docx ,   Final HCPS Questionnaire_Spanish_09302019_psg.docx ,   Final HCPS Questionnaire_Vietnamese_09302019_psg.docx ,   HCPS Questionnaire_Tagalog_09302019_psg.docx ,   Incentive Receipt (English)_psg.docx ,   Incentive Receipt_TChinese_psg.docx ,   Incentive Receipt_SPA_rev_psg.docx ,   Incentive Receipt_Vietnamese_psg.docx ,   Incentive Receipt Tagalog_psg.docx
Patient Screening: Short Blessed Scale	3, 3 C, 3 S, 3 V, 3 T	Attachment 13 Short Blessed Scale Test_psg.docx ,   Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx ,   Attachment 13 Short Blessed Scale (Spanish)_psg.docx ,   Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx ,   Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
Site Recruitment and Training	2	Attachment10 National_Awardee and Site Recruitment Materials_3-23-20

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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	23,058	0	0	23,058	0	0
Annual Time Burden (Hours)	13,876	0	0	13,876	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: There is an increase in respondents, therefore an increase in burden estimates. The Final HCPS Screener is the first page of the HCPS system in which all of these forms will be located. The OMB Info. and Burden statement will be displayed on this first screen of each language.

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Annual Cost to Federal Government: $7,760,258

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 12/26/2019

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