5 Incentive Receipt (English)_psg

OMB Number (0915-0368)
Expiration date (X/XX/XXXX)

Public Burden Statement: The information collected through the Health Center Patient Survey (HCPS) informs HRSA on how health centers provide access to primary and preventative health care from the patients’ perspectives. It is the only nationally-representative survey of its type that focuses on the health care of populations seeking care at health centers. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0368 and it is valid until XX/XX/XXXX. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

Health Center Patient Survey Respondent Incentive Receipt

To show our appreciation for the time you spent answering our questions, we are authorized to give you a cash incentive or a gift that is of equal value. Please indicate that you have received either the cash incentive or one of the gift items by checking the appropriate box and signing below.

 $25.00 Cash

 Visa Gift Card

 Food Voucher

 Other (specify)

Respondent’s Initials (PLEASE DO NOT SIGN YOUR NAME): ________________

Interviewer Signature: Date: ______/______/________

OMB Number (0915-0368)
Expiration date (X/XX/XXXX)

Public Burden Statement: The information collected through the Health Center Patient Survey (HCPS) informs HRSA on how health centers provide access to primary and preventative health care from the patients’ perspectives. It is the only nationally-representative survey of its type that focuses on the health care of populations seeking care at health centers. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0368 and it is valid until XX/XX/XXXX. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

Health Center Patient Survey Respondent Incentive Receipt

To show our appreciation for the time you spent answering our questions, we are authorized to give you a cash incentive or a gift that is of equal value. Please indicate that you have received either the cash incentive or one of the gift items by checking the appropriate box and signing below.

 $25.00 Cash

 Visa Gift Card

 Food Voucher

 Other (specify)

Respondent’s Initials (PLEASE DO NOT SIGN YOUR NAME): ________________

Interviewer Signature: Date: ______/______/________