Health Center Patient Survey Patient Survey Instrument

Health Center Patient Survey (HCPS_

OMB: 0915-0368

IC ID: 211602

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Information Collection (IC) Details

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Health Center Patient Survey Patient Survey Instrument
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 5 C Incentive Receipt_TChinese_psg.docx Attachment 13 Incentive Receipt_TChinese_psg.docx Yes Yes Fillable Fileable
Form 4 Final HCPS Questionnaire_English_09302019_psg.docx Attachment 1 Final HCPS Questionnaire_English_09302019_psg.docx Yes Yes Fillable Fileable
Form 4 C Final HCPS Questionnaire_Chinese_09302019_psg.docx Attachment 1 Final HCPS Questionnaire_Chinese_09302019_psg.docx Yes Yes Fillable Fileable
Form 4 S Final HCPS Questionnaire_Spanish_09302019_psg_clean.docx Attachment 1 Final HCPS Questionnaire_Spanish_09302019_psg_clean.docx Yes Yes Fillable Fileable
Form 4 S Tracked Changes Final HCPS Questionnaire_Spanish_09302019_psg.docx Attachment 1 Final HCPS Questionnaire_Spanish_09302019_psg.docx Yes Yes Fillable Fileable
Form 4 V Final HCPS Questionnaire_Vietnamese_09302019_psg.docx Attachment 1 Final HCPS Questionnaire_Vietnamese_09302019_psg.docx Yes Yes Fillable Fileable
Form 4 T HCPS Questionnaire_Tagalog_09302019_psg.docx Attachment 1 HCPS Questionnaire_Tagalog_09302019_psg.docx Yes Yes Fillable Fileable
Form 5 Incentive Receipt (English)_psg.docx Attachment 13 Incentive Receipt (English)_psg.docx Yes Yes Fillable Fileable
Form 5 S Incentive Receipt_SPA_rev_psg.docx Attachment 13 Incentive Receipt_SPA_rev_psg.docx Yes Yes Fillable Fileable
Form 5 V Incentive Receipt_Vietnamese_psg.docx Attachment 13 Incentive Receipt_Vietnamese_psg.docx Yes Yes Fillable Fileable
Form 5 T Incentive Receipt Tagalog_psg.docx Attachment 13 Incentive Receipt Tagalog_psg.docx Yes Yes Fillable Fileable

Health Health Care Services

 

9,000 0
   
Individuals or Households
 
   100 %

  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 9,000 0 9,000 0 0 0
Annual IC Time Burden (Hours) 9,000 0 9,000 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
A. 2.2 HCPS Round 1 Cognitive Interview Results_080819.docx A. 2.2 HCPS Round 1 Cognitive Interview Results_080819.docx 12/26/2019
A. 2 HCPS Round 1 Cognitive Interview Results A. 2HCPS Round 1 Cognitive Interview Results_080819.docx 12/26/2019
Attachment 13 Final Showcard Booklet_English Attachment 13 Final Showcard Booklet_English_09302019.docx 12/26/2019
Attachment 13 Final Showcard Booklet_Chinese ATTACH~4.DOC 12/26/2019
Attachment 13 Final Showcard Booklet_Spanish AT25D3~1.DOC 12/26/2019
Attachment 13 Final Showcard Booklet_Vietnamese ATTACH~3.DOC 12/26/2019
Attachment 13 Final Showcard Booklet_Tagalog ATC23D~1.DOC 12/26/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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