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Health Center Patient Survey Patient Survey Instrument

IC 211602 under ICR 202303-0915-004 · OMB 0915-0368.

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Information Collection (IC) Details

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Health Center Patient Survey Patient Survey Instrument
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 4 T HCPS Questionnaire_Tagalog_09302019_psg.docx Attachment 1 HCPS Questionnaire_Tagalog_09302019_psg.docx Yes Yes Fillable Fileable
Form 5 Incentive Receipt (English)_psg.docx Attachment 13 Incentive Receipt (English)_psg.docx Yes Yes Fillable Fileable
Form 5 C Incentive Receipt_TChinese_psg.docx Attachment 13 Incentive Receipt_TChinese_psg.docx Yes Yes Fillable Fileable
Form 5 S Incentive Receipt_SPA_rev_psg.docx Attachment 13 Incentive Receipt_SPA_rev_psg.docx Yes Yes Fillable Fileable
Form 5 V Incentive Receipt_Vietnamese_psg.docx Attachment 13 Incentive Receipt_Vietnamese_psg.docx Yes Yes Fillable Fileable
Form 5 T Incentive Receipt Tagalog_psg.docx Attachment 13 Incentive Receipt Tagalog_psg.docx Yes Yes Fillable Fileable
Form 4 2019 HCPS Questionnaire_ENGLISH 2019 HCPS Questionnaire_MASTER FILE_10072020.docx Yes Yes Fillable Fileable
Form 4 C Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx Yes Yes Fillable Fileable
Form 4 S Final HCPS Questionnaire_Spanish_10072020.docx Final HCPS Questionnaire_Spanish_10072020.docx Yes Yes Fillable Fileable
Form 4 V 2019 HCPS Questionnaire_Vietnamese_10072020. 2019 HCPS Questionnaire_Vietnamese_10072020.docx Yes Yes Fillable Fileable

Health Health Care Services

 

9,000 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 9,000 0 0 0 0 9,000
Annual IC Time Burden (Hours) 9,000 0 0 0 0 9,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
HCPS Round One Cognitive Interview Results HCPS Round 1 Cognitive Interview Results_080819.docx 03/17/2023
HCPS Round 2 Report HCPS Round 2 Cognitive Interview Report.docx 03/17/2023
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.