Health Center Patient Survey (HCPS)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 3 T Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx	Form	Modified	Available
Form 3 V Attachment 13 Short Blessed Scale Exam 2023_VIE_psg.docx	Form	Modified	Available
Form 3 S Attachment 13 Short Blessed Scale (Spanish)_psg.docx	Form	Modified	Available
Form 3 C Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx	Form	Modified	Available
Form 3 Attachment 13 Short Blessed Scale Test_psg.docx	Form	Modified	Available
Form 3 Patient Screening: Short Blessed Scale	Form	Modified	Repair queued
Form 2 Attachment10 National_Awardee and Site Recruitment Materials_3-23-20	Form	Unchanged	Available
Form 2 Site Recruitment and Training	Form	Unchanged	Repair queued
Form 1 Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx	Form	Modified	Available
Form 1 Awardee Recruitment	Form	Modified	Repair queued
Form 11 V Phone Version Assent form for Accompanied Adolescent VIE.docx	Form	Modified	Available
Form 11 S Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docx	Form	Modified	Available
Form 11 C Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docx	Form	Modified	Available
Form 11 Phone Version_Assent Form for Accompanied Adolescent.docx	Form	Modified	Available
Form 10 V Phone Version Parent or Guardian Permission form for Adolescent Final VIE.docx	Form	Modified	Available
Form 10 S Phone_Version_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_11-04-2020.docx	Form	Modified	Available
Form 10 C Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docx	Form	Modified	Available
Form 10 Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docx	Form	Modified	Available
Form 9 V Phone Version Informed Consent Form for Parent or Guardian Proxy VIE.docx	Form	Modified	Available
Form 9 S Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_11-04-2020.docx	Form	Modified	Available
Form 9 C Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docx	Form	Modified	Available
Form 9 Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docx	Form	Modified	Available
Form 8 V Phone Version Informed Consent Form for Adult Survey Participation VIE.docx	Form	Modified	Available
Form 8 S Phone Version_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_11-04-2020.docx	Form	Modified	Available
Form 8 C Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docx	Form	Modified	Available
Form 8 Phone Version_Informed Consent Form for Adult Survey Participation .docx	Form	Modified	Available
Form 7 V 2023Patient Screener_Vietnamese_10072020.docx	Form	Modified	Available
Form 7 S Final HCPS Screener_Spanish_ 2023_10072020	Form	Modified	Available
Form 7 C Final HCPS Screener_Chinese_2023_For Revisions.docx	Form	Modified	Available
Form 7 2023 HCPS Patient Screener ENGLISH	Form	Modified	Available
Form 12 Contact Summary Report Form Final_psg.docx	Form	Modified	Available
Form 10 T Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx	Form	Modified	Available
Form 9 T Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx	Form	Modified	Available
Form 8 T _Informed Consent Form for Adult Survey Participation reviewed Final Tagalog_09-27-2019_psg.docx	Form	Modified	Available
Form 7 T Final HCPS Screener Tagalog_09302019_psg.docx	Form	Modified	Available
Form 6 National_Patient Arrival and Referral Tracking Form Final_psg.docx	Form	Modified	Available
Form 6 Health Center Patient Survey Patient Screening Form	Form	Modified	Repair queued
Form 4 V 2019 HCPS Questionnaire_Vietnamese_10072020.	Form	Modified	Available
Form 4 S Final HCPS Questionnaire_Spanish_10072020.docx	Form	Modified	Available
Form 4 C Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx	Form	Modified	Available
Form 4 2019 HCPS Questionnaire_ENGLISH	Form	Modified	Available
Form 5 T Incentive Receipt Tagalog_psg.docx	Form	Modified	Available
Form 5 V Incentive Receipt_Vietnamese_psg.docx	Form	Modified	Available
Form 5 S Incentive Receipt_SPA_rev_psg.docx	Form	Modified	Available
Form 5 C Incentive Receipt_TChinese_psg.docx	Form	Modified	Available
Form 5 Incentive Receipt (English)_psg.docx	Form	Modified	Available
Form 4 T HCPS Questionnaire_Tagalog_09302019_psg.docx	Form	Modified	Available
Form 4 T Health Center Patient Survey Patient Survey Instrument	Form	Modified	Repair queued
OMB Comments on 0915-0368 -Supporting Statement A HCPS EXTENSION - 20221213 Complete.docx	Supporting Statement A	Uploaded 2023-03-21	Repair queued
0368 - Supporting Statement B HCPS Renewal - 20221213.docx	Supporting Statement B	Uploaded 2023-03-20	Repair queued
Attachment 13 2019 Critical Incident Form_psg.docx	Supplementary Document	Uploaded 2023-03-20	Repair queued
Attachment 13 2019 Critical Incident Protocol_In&Out Site.docx	Supplementary Document	Uploaded 2023-03-20	Repair queued
Attachment 13_2019 Receptionist Recruitment Script_English.docx	Supplementary Document	Uploaded 2023-03-20	Repair queued
Attachment 13 Iinterview Appointment Card English.doc	Supplementary Document	Uploaded 2019-12-26	Repair queued
Attachment 13 2019 FI JobAid_Train Receptionists_final.docx	Supplementary Document	Uploaded 2023-03-20	Repair queued
Attachment 9 Sampling Strata_final.docx	Supplementary Document	Uploaded 2023-03-20	Repair queued
Attachment 8_Survey Methodology and Selection Specification.pdf	Supplementary Document	Uploaded 2023-03-20	Repair queued
Attachment 7_Statistical Design Plan.pdf	Supplementary Document	Uploaded 2023-03-20	Repair queued
Attachment 6 Analysis Plan Overview_2019_final.docx	Supplementary Document	Uploaded 2023-03-20	Repair queued
Attachment 5 2019 RTI Staff Privacy Pledge.docx	Supplementary Document	Uploaded 2023-03-20	Repair queued
Attachment 4 TAP_Member_List_2019.xlsx	Supplementary Document	Uploaded 2023-03-20	Repair queued
HCPS Round 2 Cognitive Interview Report.docx	Supplementary Document	Uploaded 2023-03-20	Repair queued
HCPS Round 1 Cognitive Interview Results_080819.docx	Supplementary Document	Uploaded 2023-03-20	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
239087	Patient Screening: Short Blessed Scale	Form	Modified	Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
239087	Patient Screening: Short Blessed Scale	Form	Modified	Attachment 13 Short Blessed Scale Exam 2023_VIE_psg.docx
239087	Patient Screening: Short Blessed Scale	Form	Modified	Attachment 13 Short Blessed Scale (Spanish)_psg.docx
239087	Patient Screening: Short Blessed Scale	Form	Modified	Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx
239087	Patient Screening: Short Blessed Scale	Form	Modified	Attachment 13 Short Blessed Scale Test_psg.docx
239087	Patient Screening: Short Blessed Scale	Form	Modified
239085	Site Recruitment and Training	Form	Unchanged	Attachment10 National_Awardee and Site Recruitment Materials_3-23-20
239085	Site Recruitment and Training	Form	Unchanged
239084	Awardee Recruitment	Form	Modified	Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx
239084	Awardee Recruitment	Form	Modified
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version Assent form for Accompanied Adolescent VIE.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version_Assent Form for Accompanied Adolescent.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version Parent or Guardian Permission form for Adolescent Final VIE.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone_Version_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_11-04-2020.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version Informed Consent Form for Parent or Guardian Proxy VIE.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_11-04-2020.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version Informed Consent Form for Adult Survey Participation VIE.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_11-04-2020.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Phone Version_Informed Consent Form for Adult Survey Participation .docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	2023Patient Screener_Vietnamese_10072020.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Final HCPS Screener_Spanish_ 2023_10072020
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Final HCPS Screener_Chinese_2023_For Revisions.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	2023 HCPS Patient Screener ENGLISH
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Contact Summary Report Form Final_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	_Informed Consent Form for Adult Survey Participation reviewed Final Tagalog_09-27-2019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	Final HCPS Screener Tagalog_09302019_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified	National_Patient Arrival and Referral Tracking Form Final_psg.docx
211603	Health Center Patient Survey Patient Screening Form	Form	Modified
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	2019 HCPS Questionnaire_Vietnamese_10072020.
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Final HCPS Questionnaire_Spanish_10072020.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	2019 HCPS Questionnaire_ENGLISH
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Incentive Receipt Tagalog_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Incentive Receipt_Vietnamese_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Incentive Receipt_SPA_rev_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Incentive Receipt_TChinese_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	Incentive Receipt (English)_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified	HCPS Questionnaire_Tagalog_09302019_psg.docx
211602	Health Center Patient Survey Patient Survey Instrument	Form	Modified

ICR Details

OMB Control No: 0915-0368	ICR Reference No: 202303-0915-004
Status: Historical Active	Previous ICR Reference No: 202012-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No: 19425
Title: Health Center Patient Survey (HCPS)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/27/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/22/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2026	36 Months From Approved	04/30/2023
Responses	23,058	0	23,058
Time Burden (Hours)	13,876	0	13,876
Cost Burden (Dollars)	0	0	0

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Abstract: The HCPS will gather information that will assist policymakers’ assessment of how well HRSA supported health centers are able to meet health care needs and complement data that are not routinely collected from other HRSA data sources. The respondents are health center patients. Interviews are estimated to take approximately 60 minutes.

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Authorizing Statute(s): US Code: 42 USC 330-331, 254b,d Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 361	01/04/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 16452	03/17/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Awardee Recruitment	1	Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx
Health Center Patient Survey Patient Screening Form	8 S, 11 V, 6, 8, 8 C, 7 T, 8 V, 9, 9 C, 8 T, 9 S, 10, 10 C, 10 S, 9 T, 10 V, 11, 10 T, 11 C, 11 S, 12, 9 V, 7, 7 C, 7 S, 7 V	National_Patient Arrival and Referral Tracking Form Final_psg.docx ,   Final HCPS Screener Tagalog_09302019_psg.docx ,   _Informed Consent Form for Adult Survey Participation reviewed Final Tagalog_09-27-2019_psg.docx ,   Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx ,   Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx ,   Contact Summary Report Form Final_psg.docx ,   2023 HCPS Patient Screener ENGLISH ,   Final HCPS Screener_Chinese_2023_For Revisions.docx ,   Final HCPS Screener_Spanish_ 2023_10072020 ,   2023Patient Screener_Vietnamese_10072020.docx ,   Phone Version_Informed Consent Form for Adult Survey Participation .docx ,   Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docx ,   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 VIE.docx ,   Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docx ,   Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docx ,   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 VIE.docx ,   Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docx ,   Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docx ,   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 Final VIE.docx ,   Phone Version_Assent Form for Accompanied Adolescent.docx ,   Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docx ,   Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docx ,   Phone Version Assent form for Accompanied Adolescent VIE.docx
Health Center Patient Survey Patient Survey Instrument	5 C, 4 T, 5, 5 S, 5 V, 5 T, 4 C, 4, 4 S, 4 V	HCPS Questionnaire_Tagalog_09302019_psg.docx ,   Incentive Receipt (English)_psg.docx ,   Incentive Receipt_TChinese_psg.docx ,   Incentive Receipt_SPA_rev_psg.docx ,   Incentive Receipt_Vietnamese_psg.docx ,   Incentive Receipt Tagalog_psg.docx ,   2019 HCPS Questionnaire_ENGLISH ,   Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx ,   Final HCPS Questionnaire_Spanish_10072020.docx ,   2019 HCPS Questionnaire_Vietnamese_10072020.
Patient Screening: Short Blessed Scale	3, 3 C, 3 S, 3 V, 3 T	Attachment 13 Short Blessed Scale Test_psg.docx ,   Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx ,   Attachment 13 Short Blessed Scale (Spanish)_psg.docx ,   Attachment 13 Short Blessed Scale Exam 2023_VIE_psg.docx ,   Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
Site Recruitment and Training	2	Attachment10 National_Awardee and Site Recruitment Materials_3-23-20

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	23,058	23,058	0	0	0	0
Annual Time Burden (Hours)	13,876	13,876	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $7,760,258

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/22/2023

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