Information Collection

Health Center Patient Survey Patient Survey Instrument

IC 211602 under ICR 201912-0915-001 · OMB 0915-0368.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0368 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 C Health Center Patient Survey Patient Survey Instrument	Form
4 Final HCPS Questionnaire_English_09302019_psg.docx Attachment 1 Final HCPS Questionnaire_English_09302019_psg.docx	Form
4 C Final HCPS Questionnaire_Chinese_09302019_psg.docx Attachment 1 Final HCPS Questionnaire_Chinese_09302019_psg.docx	Form
4 S Final HCPS Questionnaire_Spanish_09302019_psg_clean.docx Attachment 1 Final HCPS Questionnaire_Spanish_09302019_psg_clean.docx	Form
4 S Tracked Change Final HCPS Questionnaire_Spanish_09302019_psg.docx Attachment 1 Final HCPS Questionnaire_Spanish_09302019_psg.docx	Form
4 V Final HCPS Questionnaire_Vietnamese_09302019_psg.docx Attachment 1 Final HCPS Questionnaire_Vietnamese_09302019_psg.docx	Form
4 T HCPS Questionnaire_Tagalog_09302019_psg.docx Attachment 1 HCPS Questionnaire_Tagalog_09302019_psg.docx	Form
5 Incentive Receipt (English)_psg.docx Attachment 13 Incentive Receipt (English)_psg.docx	Form
5 C Incentive Receipt_TChinese_psg.docx Attachment 13 Incentive Receipt_TChinese_psg.docx	Form
5 S Incentive Receipt_SPA_rev_psg.docx Attachment 13 Incentive Receipt_SPA_rev_psg.docx	Form
5 V Incentive Receipt_Vietnamese_psg.docx Attachment 13 Incentive Receipt_Vietnamese_psg.docx	Form
5 T Incentive Receipt Tagalog_psg.docx Attachment 13 Incentive Receipt Tagalog_psg.docx	Form
A. 2.2 HCPS Round 1 Cognitive Interview Results_080819.docx A. 2.2 HCPS Round 1 Cognitive Interview Results_080819.docx	IC Document
A. 2HCPS Round 1 Cognitive Interview Results_080819.docx A. 2 HCPS Round 1 Cognitive Interview Results	IC Document
Attachment 13 Final Showcard Booklet_English_09302019.docx Attachment 13 Final Showcard Booklet_English	IC Document
ATTACH~4.DOC Attachment 13 Final Showcard Booklet_Chinese	IC Document
AT25D3~1.DOC Attachment 13 Final Showcard Booklet_Spanish	IC Document
ATTACH~3.DOC Attachment 13 Final Showcard Booklet_Vietnamese	IC Document
ATC23D~1.DOC Attachment 13 Final Showcard Booklet_Tagalog	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Health Center Patient Survey Patient Survey Instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,000	9,000
Annual IC Time Burden (Hours)	9,000	9,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.