Awardee Recruitment

Health Center Patient Survey (HCPS_

⚠️ Notice: This information collection may be referencing outdated material.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 1 Awardee Recruitment Form
1 Attachment10 National_Awardee and Site Recruitment Mater Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx Form

Information Collection (IC) Details

IC Title:	Awardee Recruitment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx	Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 220	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	220	220
Annual IC Time Burden (Hours)	440	440
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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