Information Collection

Health Center Patient Survey Patient Survey Instrument

IC 211602 under ICR 202012-0915-002 · OMB 0915-0368.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0368 can be found here:

2023-03-22 - Extension without change of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 T Health Center Patient Survey Patient Survey Instrument	Form
4 T HCPS Questionnaire_Tagalog_09302019_psg.docx Attachment 1 HCPS Questionnaire_Tagalog_09302019_psg.docx	Form
5 Incentive Receipt (English)_psg.docx Attachment 13 Incentive Receipt (English)_psg.docx	Form
5 C Incentive Receipt_TChinese_psg.docx Attachment 13 Incentive Receipt_TChinese_psg.docx	Form
5 S Incentive Receipt_SPA_rev_psg.docx Attachment 13 Incentive Receipt_SPA_rev_psg.docx	Form
5 V Incentive Receipt_Vietnamese_psg.docx Attachment 13 Incentive Receipt_Vietnamese_psg.docx	Form
5 T Incentive Receipt Tagalog_psg.docx Attachment 13 Incentive Receipt Tagalog_psg.docx	Form
4 2019 HCPS Questionnaire_ENGLISH 2019 HCPS Questionnaire_MASTER FILE_10072020.docx	Form
4 C Final HCPS Questionnaire_Chinese_10-07-2020_For Revision Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx	Form
4 S Final HCPS Questionnaire_Spanish_10072020.docx Final HCPS Questionnaire_Spanish_10072020.docx	Form
4 V 2019 HCPS Questionnaire_Vietnamese_10072020. 2019 HCPS Questionnaire_Vietnamese_10072020.docx	Form
A. 2.2 HCPS Round 1 Cognitive Interview Results_080819.docx A. 2.2 HCPS Round 1 Cognitive Interview Results_080819.docx	IC Document
A. 2HCPS Round 1 Cognitive Interview Results_080819.docx A. 2 HCPS Round 1 Cognitive Interview Results	IC Document
ATC23D~1.DOC Attachment 13 Final Showcard Booklet_Tagalog	IC Document
2019 Showcard Booklet_English_10072020.docx 2019 Showcard Booklet_English_10072020	IC Document
Final Showcard Booklet_Chinese_10-07-2020_For Revisions.docx Final Showcard Booklet_Chinese_10-07-2020_For Revisions	IC Document
Final Showcard Booklet_Spanish_10072020.docx Final Showcard Booklet_Spanish_10072020	IC Document
2019 Showcard Booklet_Vietnamese_10072020.docx 2019 Showcard Booklet_Vietnamese_10072020	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Health Center Patient Survey Patient Survey Instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	4 T	HCPS Questionnaire_Tagalog_09302019_psg.docx	Attachment 1 HCPS Questionnaire_Tagalog_09302019_psg.docx	Yes	Yes	Fillable Fileable
Form	5	Incentive Receipt (English)_psg.docx	Attachment 13 Incentive Receipt (English)_psg.docx	Yes	Yes	Fillable Fileable
Form	5 C	Incentive Receipt_TChinese_psg.docx	Attachment 13 Incentive Receipt_TChinese_psg.docx	Yes	Yes	Fillable Fileable
Form	5 S	Incentive Receipt_SPA_rev_psg.docx	Attachment 13 Incentive Receipt_SPA_rev_psg.docx	Yes	Yes	Fillable Fileable
Form	5 V	Incentive Receipt_Vietnamese_psg.docx	Attachment 13 Incentive Receipt_Vietnamese_psg.docx	Yes	Yes	Fillable Fileable
Form	5 T	Incentive Receipt Tagalog_psg.docx	Attachment 13 Incentive Receipt Tagalog_psg.docx	Yes	Yes	Fillable Fileable
Form	4	2019 HCPS Questionnaire_ENGLISH	2019 HCPS Questionnaire_MASTER FILE_10072020.docx	Yes	Yes	Fillable Fileable
Form	4 C	Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx	Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx	Yes	Yes	Fillable Fileable
Form	4 S	Final HCPS Questionnaire_Spanish_10072020.docx	Final HCPS Questionnaire_Spanish_10072020.docx	Yes	Yes	Fillable Fileable
Form	4 V	2019 HCPS Questionnaire_Vietnamese_10072020.	2019 HCPS Questionnaire_Vietnamese_10072020.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	9,000	9,000
Annual IC Time Burden (Hours)	9,000	9,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
A. 2.2 HCPS Round 1 Cognitive Interview Results_080819.docx	A. 2.2 HCPS Round 1 Cognitive Interview Results_080819.docx	12/26/2019
A. 2 HCPS Round 1 Cognitive Interview Results	A. 2HCPS Round 1 Cognitive Interview Results_080819.docx	12/26/2019
Attachment 13 Final Showcard Booklet_Tagalog	ATC23D~1.DOC	12/26/2019
2019 Showcard Booklet_English_10072020	2019 Showcard Booklet_English_10072020.docx	12/11/2020
Final Showcard Booklet_Chinese_10-07-2020_For Revisions	Final Showcard Booklet_Chinese_10-07-2020_For Revisions.docx	12/11/2020
Final Showcard Booklet_Spanish_10072020	Final Showcard Booklet_Spanish_10072020.docx	12/11/2020
2019 Showcard Booklet_Vietnamese_10072020	2019 Showcard Booklet_Vietnamese_10072020.docx	12/11/2020

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