Patient Screening: Short Blessed Scale

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⚠️ Notice: This information collection may be referencing outdated material.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 3 Patient Screening: Short Blessed Scale Form
3 Attachment 13 Short Blessed Scale Test_psg.docx Attachment 13 Short Blessed Scale Test_psg.docx Form
3 C Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx Form
3 S Attachment 13 Short Blessed Scale (Spanish)_psg.docx Attachment 13 Short Blessed Scale (Spanish)_psg.docx Form
3 V Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx Form
3 T Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx Form

Information Collection (IC) Details

IC Title:	Patient Screening: Short Blessed Scale	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3	Attachment 13 Short Blessed Scale Test_psg.docx	Attachment 13 Short Blessed Scale Test_psg.docx	Yes	Yes	Fillable Fileable
Form	3 C	Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx	Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx	Yes	Yes	Fillable Fileable
Form	3 S	Attachment 13 Short Blessed Scale (Spanish)_psg.docx	Attachment 13 Short Blessed Scale (Spanish)_psg.docx	Yes	Yes	Fillable Fileable
Form	3 V	Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx	Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx	Yes	Yes	Fillable Fileable
Form	3 T	Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx	Attachment 13 Short Blessed Scale Exam_Tagalog_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: 18	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	18	18
Annual IC Time Burden (Hours)	1	1
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.