Site Recruitment and Training

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⚠️ Notice: This information collection may be referencing outdated material.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 2 Site Recruitment and Training Form
2 Attachment10 National_Awardee and Site Recruitment Mater Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx Form
AT0E7D~1.DOC Attachment 13 Receptionist Recruitment Script_English_TChinese IC Document
ATTACH~3.DOC Attachment 13 Receptionist Recruitment Script_Spanish IC Document
ATTACH~1.DOC Attachment 13 Receptionist Recruitment Script_Vietnamese IC Document
AT8625~1.DOC Attachment 13 Receptionist Recruitment Script_Tagalog IC Document
AT5587~1.DOC Attachment 13 Interviewer Recruitment Script final_TChinese IC Document
ATTACH~2.DOC Attachment 13 Interviewer Recruitment Script final_Spanish IC Document
ATAF25~1.DOC Attachment 13 Interviewer Recruitment Script final_Tagalog IC Document
AT3EB9~1.DOC Attachment 13 Interviewer Recruitment Script final_Vietnamese IC Document

Information Collection (IC) Details

IC Title:	Site Recruitment and Training	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	2	Attachment10 National_Awardee and Site Recruitment Materials_3-23-20	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: 700	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	700	700
Annual IC Time Burden (Hours)	2,205	2,205
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 13 Receptionist Recruitment Script_English_TChinese	AT0E7D~1.DOC	12/26/2019
Attachment 13 Receptionist Recruitment Script_Spanish	ATTACH~3.DOC	12/26/2019
Attachment 13 Receptionist Recruitment Script_Vietnamese	ATTACH~1.DOC	12/26/2019
Attachment 13 Receptionist Recruitment Script_Tagalog	AT8625~1.DOC	12/26/2019
Attachment 13 Interviewer Recruitment Script final_TChinese	AT5587~1.DOC	12/26/2019
Attachment 13 Interviewer Recruitment Script final_Spanish	ATTACH~2.DOC	12/26/2019
Attachment 13 Interviewer Recruitment Script final_Tagalog	ATAF25~1.DOC	12/26/2019
Attachment 13 Interviewer Recruitment Script final_Vietnamese	AT3EB9~1.DOC	12/26/2019

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