Information Collection

Health Center Patient Survey Patient Screening Form

IC 211603 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 8 S Health Center Patient Survey Patient Screening Form Form
6 National_Patient Arrival and Referral Tracking Form Fina Attachment11 National_Patient Arrival and Referral Tracking Form Final_psg.docx Form
7 T Final HCPS Screener Tagalog_09302019_psg.docx Attachment 12 HCPS Patient Screener_Tagalog_psg.docx Form
8 T _Informed Consent Form for Adult Survey Participation re Attachment 13 Informed Consent Form for Adult Survey Participation Tagalog_psg.docx Form
9 T Informed Consent Form for Parent or Guardian Proxy Inter Attachment 13 Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx Form
10 T Parent or Guardian Permission Form for Adolescent Tagalo Attachment 13 Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx Form
12 Contact Summary Report Form Final_psg.docx Attachment 13 Contact Summary Report Form Final_psg.docx Form
7 2019 HCPS Patient Screener ENGLISH 2019 HCPS Patient Screener_MASTER FILE_10072020.docx Form
7 C Final HCPS Screener_Chinese_10-07-2020_For Revisions.doc Final HCPS Screener_Chinese_10-07-2020_For Revisions.docx Form
7 S Final HCPS Screener_Spanish_10072020 Final HCPS Screener_Spanish_10072020.docx Form
7 V 2019 Patient Screener_Vietnamese_10072020.docx 2019 Patient Screener_Vietnamese_10072020.docx Form
8 Phone Version_Informed Consent Form for Adult Survey Par Phone Version_Informed Consent Form for Adult Survey Participation .docx Form
8 C Phone Version Informed Consent Form for Adult Survey Par Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docx Form
8 S Phone Version_Informed Consent Form for Adult Survey Par Phone Version_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_11-04-2020.docx Form
8 V Phone Version Informed Consent Form for Adult Survey Par Phone Version Informed Consent Form for Adult Survey Participation VIE.docx Form
9 Phone Version_Informed Consent Form for Parent or Guardi Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docx Form
9 C Phone Version Informed Consent Form for Parent or Guardi Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docx Form
9 S Phone Version_Informed Consent Form for Parent or Guardi Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_11-04-2020.docx Form
9 V Phone Version Informed Consent Form for Parent or Guardi Phone Version Informed Consent Form for Parent or Guardian Proxy VIE.docx Form
10 Phone Version_Parent or Guardian Permission form for Acc Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docx Form
10 C Phone Version Parent or Guardian Permission form for Ado Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docx Form
10 S Phone_Version_Parent or Guardian Permission form for Ado Phone_Version_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_11-04-2020.docx Form
10 V Phone Version Parent or Guardian Permission form for Ado Phone Version Parent or Guardian Permission form for Adolescent Final VIE.docx Form
11 Phone Version_Assent Form for Accompanied Adolescent.doc Phone Version_Assent Form for Accompanied Adolescent.docx Form
11 C Phone Version Assent Form for Accompanied Adolescent Fin Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docx Form
11 S Phone Version Assent Form for Accompanied Adolescent rev Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docx Form
11 V Phone Version Assent form for Accompanied Adolescent VIE Phone Version Assent form for Accompanied Adolescent VIE.docx Form
HCPS_brochure_10_26_20_GRAY_NoYr.pdf HCPS_brochure_10_26_20_GRAY_NoYr IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Center Patient Survey Patient Screening Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	6	National_Patient Arrival and Referral Tracking Form Final_psg.docx	Attachment11 National_Patient Arrival and Referral Tracking Form Final_psg.docx	Yes	Yes	Fillable Fileable
Form	7 T	Final HCPS Screener Tagalog_09302019_psg.docx	Attachment 12 HCPS Patient Screener_Tagalog_psg.docx	Yes	Yes	Fillable Fileable
Form	8 T	_Informed Consent Form for Adult Survey Participation reviewed Final Tagalog_09-27-2019_psg.docx	Attachment 13 Informed Consent Form for Adult Survey Participation Tagalog_psg.docx	Yes	Yes	Fillable Fileable
Form	9 T	Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx	Attachment 13 Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx	Yes	Yes	Fillable Fileable
Form	10 T	Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx	Attachment 13 Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx	Yes	Yes	Fillable Fileable
Form	12	Contact Summary Report Form Final_psg.docx	Attachment 13 Contact Summary Report Form Final_psg.docx	Yes	Yes	Fillable Fileable
Form	7	2019 HCPS Patient Screener ENGLISH	2019 HCPS Patient Screener_MASTER FILE_10072020.docx	Yes	Yes	Fillable Fileable
Form	7 C	Final HCPS Screener_Chinese_10-07-2020_For Revisions.docx	Final HCPS Screener_Chinese_10-07-2020_For Revisions.docx	Yes	Yes	Fillable Fileable
Form	7 S	Final HCPS Screener_Spanish_10072020	Final HCPS Screener_Spanish_10072020.docx	Yes	Yes	Fillable Fileable
Form	7 V	2019 Patient Screener_Vietnamese_10072020.docx	2019 Patient Screener_Vietnamese_10072020.docx	Yes	Yes	Fillable Fileable
Form	8	Phone Version_Informed Consent Form for Adult Survey Participation .docx	Phone Version_Informed Consent Form for Adult Survey Participation .docx	Yes	Yes	Fillable Fileable
Form	8 C	Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docx	Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docx	Yes	Yes	Fillable Fileable
Form	8 S	Phone Version_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_11-04-2020.docx	Phone Version_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_11-04-2020.docx	Yes	Yes	Fillable Fileable
Form	8 V	Phone Version Informed Consent Form for Adult Survey Participation VIE.docx	Phone Version Informed Consent Form for Adult Survey Participation VIE.docx	Yes	Yes	Fillable Fileable
Form	9	Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docx	Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docx	Yes	Yes	Fillable Fileable
Form	9 C	Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docx	Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docx	Yes	Yes	Fillable Fileable
Form	9 S	Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_11-04-2020.docx	Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_11-04-2020.docx	Yes	Yes	Fillable Fileable
Form	9 V	Phone Version Informed Consent Form for Parent or Guardian Proxy VIE.docx	Phone Version Informed Consent Form for Parent or Guardian Proxy VIE.docx	Yes	Yes	Fillable Fileable
Form	10	Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docx	Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docx	Yes	Yes	Fillable Fileable
Form	10 C	Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docx	Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docx	Yes	Yes	Fillable Fileable
Form	10 S	Phone_Version_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_11-04-2020.docx	Phone_Version_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_11-04-2020.docx	Yes	Yes	Fillable Fileable
Form	10 V	Phone Version Parent or Guardian Permission form for Adolescent Final VIE.docx	Phone Version Parent or Guardian Permission form for Adolescent Final VIE.docx	Yes	Yes	Fillable Fileable
Form	11	Phone Version_Assent Form for Accompanied Adolescent.docx	Phone Version_Assent Form for Accompanied Adolescent.docx	Yes	Yes	Fillable Fileable
Form	11 C	Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docx	Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docx	Yes	Yes	Fillable Fileable
Form	11 S	Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docx	Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docx	Yes	Yes	Fillable Fileable
Form	11 V	Phone Version Assent form for Accompanied Adolescent VIE.docx	Phone Version Assent form for Accompanied Adolescent VIE.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: 13,120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	13,120	13,120
Annual IC Time Burden (Hours)	2,230	2,230
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HCPS_brochure_10_26_20_GRAY_NoYr	HCPS_brochure_10_26_20_GRAY_NoYr.pdf	12/11/2020

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