12 Contact Summary Report Form Final_psg

Health Center Patient Survey (HCPS_

Attachment 13 Contact Summary Report Form Final_psg

Health Center Patient Survey Patient Screening Form

OMB: 0915-0368

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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


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
Authorderecho
File Modified0000-00-00
File Created2021-01-12

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