Health Center Patient Survey Patient Screening Form

Health Center Patient Survey (HCPS_

OMB: 0915-0368

IC ID: 211603

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IC Document
Information Collection (IC) Details

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Health Center Patient Survey Patient Screening Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

13,120 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 13,120 0 0 0 0 13,120
Annual IC Time Burden (Hours) 2,230 0 0 0 0 2,230
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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