12 Contact Summary Report Form Final_psg

OMB# 0915-0368
Expiration Date XX/XX/XXXX

Public Burden Statement: The information collected through the Health Center Patient Survey (HCPS) informs HRSA on how health centers provide access to primary and preventative health care from the patients’ perspectives. It is the only nationally-representative survey of its type that focuses on the health care of populations seeking care at health centers. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0368 and it is valid until XX/XX/XXXX. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

Contact Summary Report Form

Case ID: _______________________________ FI Name: _______________________________ FS Name: ___________________________________ Awardee Number: ________________________ Awardee Name: _______________________________ Site Number: ____________________________ Site Name: ___________________________________
RECORD OF CONTACTS
DATE	TIME	TYPE OF INTERVIEW		STATUS*	COMMENTS
*IF AN APPOINTMENT IS SET FOR A LATER TIME, DOCUMENT THE RESPONDENT’S FIRST NAME ONLY, CONTACT NUMBER, THE LOCATION AND TIME OF THE APPOINTMENT, AND THE PARENT/GUARDIAN NAME (IF APPLICABLE) IN THE COMMENTS SECTION. Interviewer Notes: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
SCREENER AND MAIN INTERVIEW STATUS CODES
PENDING CODES: 1036 No Action Taken (CMS) 1130 Access Denied to Building (off-site) 1180 Respondent Unlocatable 1203 No One Home 1205 Respondent Not at Home 1230 Respondent Unavailable, Come Back 1242 Respondent Incarcerated/Institutionalized 1243 Respondent Moved out of Country 1244 Respondent Moved Out of Interviewing Area 1254 Case Mistakenly Created 1292 Appointment Made 1294 Appointment Broken (CMS) 1295 Break-Off, Appointment Made (CMS) 1296 Break-Off/Friendly, No Appointment (CMS) 1297 Appointment Made by Other (off site) 1390 Ineligible, Quota Full (CMS) 1410 Temporary Refusal by Respondent 1420 Temporary Refusal by Parent/Guardian 1430 Temporary Refusal by Other 1435 Break-Off, Refusal (CMS) 1530 Language Barrier Other Language (Specify) 1554 Physically, Mentally Incapable 1550 Respondent Deceased 1589 Other non-Interview (Specify)			FINALCODES: 2170 Final Unable to Reschedule Appointment 2180 Respondent Unlocatable 2231 Ineligible, Unaccompanied Minor (CMS) 2242 Respondent Incarcerated 2243 Respondent Moved out of Country 2244 Respondent Moved Out of Interviewing Area 2254 Case Mistakenly Created/Generated 2320 Ineligible, Did Not Receive Services at HC (CMS) 2348 Ineligible, Non-Interview 2390 Ineligible, Quota Full 2410 Final Refusal by Respondent 2420 Final Refusal by Parent/Guardian 2430 Final Refusal by Other 2530 Language Barrier Other Language (Specify) 2554 Physically, Mentally Incapable 2550 Respondent Deceased 2570 Other Non-Interview – Fraudulent 2584 Other Non-Interview – Eligible 2589 Other Non-Interview (Specify) 2690 Screener Interview Completed 2691 Main Interview Break-off/Partial Interview 2692 Main Interview Completed On Site 2693 Main Interview Completed Off Site