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⚠️ Notice: This information collection may be referencing outdated material.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

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:

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 %

	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

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.