Information Collection Request
Health Center Patient Survey (HCPS)
ICR 202303-0915-004 · OMB 0915-0368 · Received in OIRA
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form 3 Patient Screening: Short Blessed Scale |
Form | Modified | Repair queued |
| Form 2 Site Recruitment and Training |
Form | Unchanged | Repair queued |
| Form 1 Awardee Recruitment |
Form | Modified | Missing upstream |
| Form 6 Health Center Patient Survey Patient Screening Form |
Form | Modified | Repair queued |
| 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 | Missing upstream |
| 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
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 239087 |  Patient Screening: Short Blessed Scale |
Form | Modified | |
| 239085 | Site Recruitment and Training |
Form | Unchanged | |
| 239084 | Awardee Recruitment |
Form | Modified | |
| 211603 | Health Center Patient Survey Patient Screening Form |
Form | Modified | |
| 211602 | Health Center Patient Survey Patient Survey Instrument |
Form | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/HSA |
| OMB Control No | 0915-0368 |
| Type of Information Collection | Extension without change of a currently approved collection |
| Previous ICR Reference No | 202012-0915-002 |
| Agency Tracking No | 19425 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |