6 National_Patient Arrival and Referral Tracking Form Fina

OMB Number (0915-0368)
Expiration date (X/XX/XXXX)

Public Burden Statement: The information collected through the Health Center Patient Survey (HCPS) informs HRSA on how health centers provide access to primary and preventative health care from the patients’ perspectives. It is the only nationally-representative survey of its type that focuses on the health care of populations seeking care at health centers. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0368 and it is valid until XX/XX/XXXX. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

PATIENT ARRIVAL AND REFERRAL TRACKING FORM

Please keep track of the number of patients who register for services, the number of patients eligible for the study, and the number of patients you refer to the field interviewer while the field interviewer is at the site to conduct data collection. You may either use tally marks to count patients as they enter or complete this table based on the sign-in sheet or appointment list before the interviewer leaves this health center.

Definitions:

PATIENTS REGISTERED FOR SERVICES = Patients who sign in or register while field interview is on site.

ELIGIBLE PATIENTS = Patients that meet the following criteria: 1) the patient has received services at the health center for the last 12 months, and 2) the patient is not an unaccompanied minor aged 13-17.

PATIENTS REFERRED TO FIELD INTERVIEWER= Patients who were provided information about the interview by the receptionist and referred to the field interviewer.

Patients who register for services

Patient Eligible?

Age

Race/Ethnicity

Veteran Status

Referred Patient to Interviewer?

Yes

No

Under 65 years old

65 years and older

Asian

American Indian/Alaska Native

Native Hawaiian/other Pacific Islander

Races or ethnicity other than Asian, American Indian/Alaska Native or Native Hawaiian/ other Pacific Islander

Veteran

Not A Veteran

Yes

No

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6

Patient 7

Patient 8

Patient 9

Patient 10