Information Collection

Health Center Patient Survey Patient Screening Form

IC 211603 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⚠️ Notice: This information collection may be referencing outdated material.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 6 Health Center Patient Survey Patient Screening Form	Form
6 National_Patient Arrival and Referral Tracking Form Fina Attachment11 National_Patient Arrival and Referral Tracking Form Final_psg.docx	Form
7 Final HCPS Screener_English_09302019_psg.docx Attachment 12 Final HCPS Screener_English_09302019_psg.docx	Form
7 C Final HCPS Screener_Chinese_09302019_psg.docx Attachment 12 Final HCPS Screener_Chinese_09302019_psg.docx	Form
7 S Final HCPS Screener_Spanish_09302019_psg.docx Attachment 12 Final HCPS Screener_Spanish_09302019_psg.docx	Form
7 T Final HCPS Screener_Spanish_09302019_psg.docx Attachment 12 HCPS Patient Screener_Tagalog_psg.docx	Form
7 V Final HCPS Screener_Vietnamese_09302019_psg.docx Attachment 12 Final HCPS Screener_Vietnamese_09302019_psg.docx	Form
8 Informed Consent Form for Adult Survey Participation rev Attachment13_Informed Consent Form for Adult Survey Participation reviewed Final_psg.docx	Form
8 C Informed Consent Form for Adult Survey Participation Fin Attachment 13 Informed Consent Form for Adult Survey Participation Final_TChinese_09272019_clean_psg.docx	Form
8 S Informed Consent Form for Adult Survey Participation rev Attachment13_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx	Form
8 T _Informed Consent Form for Adult Survey Participation re Attachment 13 Informed Consent Form for Adult Survey Participation Tagalog_psg.docx	Form
8 V Informed Consent Form for Adult Survey Participation VIE Attachment 13 Informed Consent Form for Adult Survey Participation VIE_09-27-2019_psg.docx	Form
9 Informed Consent Form for Parent or Guardian Proxy revie Attachment13_Informed Consent Form for Parent or Guardian Proxy reviewed Final_psg.docx	Form
9 C Informed Consent Form for Parent or Guardian Proxy Final Attachment 13 Informed Consent Form for Parent or Guardian Proxy Final_TChinese_09272019_clean_psg.docx	Form
9 S Informed Consent Form for Parent or Guardian Proxy revie Attachment13_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_09-27-2019_psg.docx	Form
9 T Informed Consent Form for Parent or Guardian Proxy Inter Attachment 13 Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx	Form
9 V Informed Consent Form for Parent or Guardian Proxy VIE_0 Attachment 13 Informed Consent Form for Parent or Guardian Proxy VIE_09-27-2019_psg.docx	Form
10 Parent or Guardian Permission form for Accompanied Adole Attachment13_Parent or Guardian Permission form for Accompanied Adolescent reviewed Final_psg.docx	Form
10 S Parent or Guardian Permission form for Adolescent review Attachment13_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx	Form
10 T Parent or Guardian Permission Form for Adolescent Tagalo Attachment 13 Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx	Form
10 V Parent or Guardian Permission form for Adolescent Final Attachment 13 Parent or Guardian Permission form for Adolescent Final VIE_09-27-2019_psg.docx	Form
10 C Parent or Guardian Permission form for Adolescent Final_ Attachment 13 Parent or Guardian Permission form for Adolescent Final_TChinese_09272019_clean_psg.docx	Form
11 Assent Form for Accompanied Adolescent reviewed Final_ps Attachment13_Assent Form for Accompanied Adolescent reviewed Final_psg.docx	Form
11 C Assent Form for Accompanied Adolescent Final_TChinese_09 Attachment 13 Assent Form for Accompanied Adolescent Final_TChinese_09272019_clean_psg.docx	Form
11 S Assent Form for Accompanied Adolescent reviewed Final_SP Attachment13_Assent Form for Accompanied Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx	Form
11 V Assent form for Accompanied Adolescent VIE_09-27-2019_ps Attachment 13 Assent form for Accompanied Adolescent VIE_09-27-2019_psg.docx	Form
12 Contact Summary Report Form Final_psg.docx Attachment 13 Contact Summary Report Form Final_psg.docx	Form
Attachment 13 HCPS_brochure_2_4_19_GRAY_NoYr.pdf Attachment 13 HCPS_brochure_2_4_19_GRAY_NoYr	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Health Center Patient Survey Patient Screening Form

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	6	National_Patient Arrival and Referral Tracking Form Final_psg.docx	Attachment11 National_Patient Arrival and Referral Tracking Form Final_psg.docx	Yes	Yes	Fillable Fileable
Form	11 S	Assent Form for Accompanied Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx	Attachment13_Assent Form for Accompanied Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx	Yes	Yes	Fillable Fileable
Form	7 C	Final HCPS Screener_Chinese_09302019_psg.docx	Attachment 12 Final HCPS Screener_Chinese_09302019_psg.docx	Yes	Yes	Fillable Fileable
Form	7	Final HCPS Screener_English_09302019_psg.docx	Attachment 12 Final HCPS Screener_English_09302019_psg.docx	Yes	Yes	Fillable Fileable
Form	7 S	Final HCPS Screener_Spanish_09302019_psg.docx	Attachment 12 Final HCPS Screener_Spanish_09302019_psg.docx	Yes	Yes	Fillable Fileable
Form	7 T	Final HCPS Screener_Spanish_09302019_psg.docx	Attachment 12 HCPS Patient Screener_Tagalog_psg.docx	Yes	Yes	Fillable Fileable
Form	7 V	Final HCPS Screener_Vietnamese_09302019_psg.docx	Attachment 12 Final HCPS Screener_Vietnamese_09302019_psg.docx	Yes	Yes	Fillable Fileable
Form	8	Informed Consent Form for Adult Survey Participation reviewed Final_psg.docx	Attachment13_Informed Consent Form for Adult Survey Participation reviewed Final_psg.docx	Yes	Yes	Fillable Fileable
Form	8 C	Informed Consent Form for Adult Survey Participation Final_TChinese_09272019_clean_psg.docx	Attachment 13 Informed Consent Form for Adult Survey Participation Final_TChinese_09272019_clean_psg.docx	Yes	Yes	Fillable Fileable
Form	8 S	Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx	Attachment13_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx	Yes	Yes	Fillable Fileable
Form	8 T	_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx	Attachment 13 Informed Consent Form for Adult Survey Participation Tagalog_psg.docx	Yes	Yes	Fillable Fileable
Form	8 V	Informed Consent Form for Adult Survey Participation VIE_09-27-2019_psg.docx	Attachment 13 Informed Consent Form for Adult Survey Participation VIE_09-27-2019_psg.docx	Yes	Yes	Fillable Fileable
Form	9	Informed Consent Form for Parent or Guardian Proxy reviewed Final_psg.docx	Attachment13_Informed Consent Form for Parent or Guardian Proxy reviewed Final_psg.docx	Yes	Yes	Fillable Fileable
Form	9 C	Informed Consent Form for Parent or Guardian Proxy Final_TChinese_09272019_clean_psg.docx	Attachment 13 Informed Consent Form for Parent or Guardian Proxy Final_TChinese_09272019_clean_psg.docx	Yes	Yes	Fillable Fileable
Form	9 S	Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_09-27-2019_psg.docx	Attachment13_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_09-27-2019_psg.docx	Yes	Yes	Fillable Fileable
Form	9 T	Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx	Attachment 13 Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx	Yes	Yes	Fillable Fileable
Form	9 V	Informed Consent Form for Parent or Guardian Proxy VIE_09-27-2019_psg.docx	Attachment 13 Informed Consent Form for Parent or Guardian Proxy VIE_09-27-2019_psg.docx	Yes	Yes	Fillable Fileable
Form	10	Parent or Guardian Permission form for Accompanied Adolescent reviewed Final_psg.docx	Attachment13_Parent or Guardian Permission form for Accompanied Adolescent reviewed Final_psg.docx	Yes	Yes	Fillable Fileable
Form	10 S	Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx	Attachment13_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx	Yes	Yes	Fillable Fileable
Form	10 T	Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx	Attachment 13 Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx	Yes	Yes	Fillable Fileable
Form	10 V	Parent or Guardian Permission form for Adolescent Final VIE_09-27-2019_psg.docx	Attachment 13 Parent or Guardian Permission form for Adolescent Final VIE_09-27-2019_psg.docx	Yes	Yes	Fillable Fileable
Form	10 C	Parent or Guardian Permission form for Adolescent Final_TChinese_09272019_clean_psg.docx	Attachment 13 Parent or Guardian Permission form for Adolescent Final_TChinese_09272019_clean_psg.docx	Yes	Yes	Fillable Fileable
Form	11	Assent Form for Accompanied Adolescent reviewed Final_psg.docx	Attachment13_Assent Form for Accompanied Adolescent reviewed Final_psg.docx	Yes	Yes	Fillable Fileable
Form	11 C	Assent Form for Accompanied Adolescent Final_TChinese_09272019_clean_psg.docx	Attachment 13 Assent Form for Accompanied Adolescent Final_TChinese_09272019_clean_psg.docx	Yes	Yes	Fillable Fileable
Form	11 V	Assent form for Accompanied Adolescent VIE_09-27-2019_psg.docx	Attachment 13 Assent form for Accompanied Adolescent VIE_09-27-2019_psg.docx	Yes	Yes	Fillable Fileable
Form	12	Contact Summary Report Form Final_psg.docx	Attachment 13 Contact Summary Report Form Final_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: 13,120

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	13,120	13,120
Annual IC Time Burden (Hours)	2,230	2,230
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 13 HCPS_brochure_2_4_19_GRAY_NoYr	Attachment 13 HCPS_brochure_2_4_19_GRAY_NoYr.pdf	12/26/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.