Site Recruitment and Training

Health Center Patient Survey (HCPS_

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 2 Site Recruitment and Training Form
2 Attachment10 National_Awardee and Site Recruitment Mater Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx Form
Receptionist Recruitment Script_Phone_version.docx Receptionist Recruitment Script_Phone_version IC Document
Receptionist Recruitment Script_English_TChinese_psg.docx Receptionist Recruitment Script_Chinese_psg IC Document
Receptionist Recruitment Script_Spanish_psg.docx Receptionist Recruitment Script_Spanish_psg IC Document
Receptionist Recruitment Script_Viet_psg.docx Receptionist Recruitment Script_Viet_psg IC Document
Interviewer Recruitment Script final_Phone_version.docx Interviewer Recruitment Script final_Phone_version IC Document
Interviewer Recruitment Script final_TChinese_Phone.docx Interviewer Recruitment Script final_TChinese_Phone IC Document
Phone Version Interviewer Recruitment Script final_Spanish_psg.docx Phone Version Interviewer Recruitment Script final_Spanish_psg IC Document
Interviewer Recruitment Script final VIET_psg.docx Interviewer Recruitment Script final VIET_psg IC Document
Attachment 13 Receptionist Recruitment Script at clinic Tagalog_psg.docx Attachment 13 Receptionist Recruitment Script at clinic Tagalog_psg IC Document
Attachment 13 Interviewer Recruitment Script_Tagalog_psg.docx Attachment 13 Interviewer Recruitment Script_Tagalog_psg IC Document
Flyer to Hand to Patients.docx Flyer to Hand to Patients IC Document

Information Collection (IC) Details

IC Title:	Site Recruitment and Training	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2	Attachment10 National_Awardee and Site Recruitment Materials_3-23-20	Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 700	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	700	700
Annual IC Time Burden (Hours)	2,205	2,205
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Receptionist Recruitment Script_Phone_version	Receptionist Recruitment Script_Phone_version.docx	12/11/2020
Receptionist Recruitment Script_Chinese_psg	Receptionist Recruitment Script_English_TChinese_psg.docx	12/11/2020
Receptionist Recruitment Script_Spanish_psg	Receptionist Recruitment Script_Spanish_psg.docx	12/11/2020
Receptionist Recruitment Script_Viet_psg	Receptionist Recruitment Script_Viet_psg.docx	12/11/2020
Interviewer Recruitment Script final_Phone_version	Interviewer Recruitment Script final_Phone_version.docx	12/11/2020
Interviewer Recruitment Script final_TChinese_Phone	Interviewer Recruitment Script final_TChinese_Phone.docx	12/11/2020
Phone Version Interviewer Recruitment Script final_Spanish_psg	Phone Version Interviewer Recruitment Script final_Spanish_psg.docx	12/11/2020
Interviewer Recruitment Script final VIET_psg	Interviewer Recruitment Script final VIET_psg.docx	12/11/2020
Attachment 13 Receptionist Recruitment Script at clinic Tagalog_psg	Attachment 13 Receptionist Recruitment Script at clinic Tagalog_psg.docx	12/11/2020
Attachment 13 Interviewer Recruitment Script_Tagalog_psg	Attachment 13 Interviewer Recruitment Script_Tagalog_psg.docx	12/11/2020
Flyer to Hand to Patients	Flyer to Hand to Patients.docx	12/11/2020

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