Health Center Patient Survey Patient Screening Form

Documents and forms in this information collection

Document Name	Document Type
Form 6 Health Center Patient Survey Patient Screening Form	Form
6 National_Patient Arrival and Referral Tracking Form Fina Attachment11 National_Patient Arrival and Referral Tracking Form Final_psg.docx	Form
6 National_Patient Arrival and Referral Tracking Form Fina Attachment11 National_Patient Arrival and Referral Tracking Form Final_psg.docx	Form
7 T Final HCPS Screener Tagalog_09302019_psg.docx Attachment 12 HCPS Patient Screener_Tagalog_psg.docx	Form
7 T Final HCPS Screener Tagalog_09302019_psg.docx Attachment 12 HCPS Patient Screener_Tagalog_psg.docx	Form
8 T _Informed Consent Form for Adult Survey Participation re Attachment 13 Informed Consent Form for Adult Survey Participation Tagalog_psg.docx	Form
8 T _Informed Consent Form for Adult Survey Participation re Attachment 13 Informed Consent Form for Adult Survey Participation Tagalog_psg.docx	Form
9 T Informed Consent Form for Parent or Guardian Proxy Inter Attachment 13 Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx	Form
9 T Informed Consent Form for Parent or Guardian Proxy Inter Attachment 13 Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx	Form
10 T Parent or Guardian Permission Form for Adolescent Tagalo Attachment 13 Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx	Form
10 T Parent or Guardian Permission Form for Adolescent Tagalo Attachment 13 Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx	Form
12 Contact Summary Report Form Final_psg.docx Attachment 13 Contact Summary Report Form Final_psg.docx	Form
12 Contact Summary Report Form Final_psg.docx Attachment 13 Contact Summary Report Form Final_psg.docx	Form
7 2023 HCPS Patient Screener ENGLISH 2019 HCPS Patient Screener_MASTER FILE_10072020.docx	Form
7 2023 HCPS Patient Screener ENGLISH 2019 HCPS Patient Screener_MASTER FILE_10072020.docx	Form
7 C Final HCPS Screener_Chinese_2023_For Revisions.docx Final HCPS Screener_Chinese_10-07-2020_For Revisions.docx	Form
7 C Final HCPS Screener_Chinese_2023_For Revisions.docx Final HCPS Screener_Chinese_10-07-2020_For Revisions.docx	Form
7 S Final HCPS Screener_Spanish_ 2023_10072020 Final HCPS Screener_Spanish_10072020.docx	Form
7 S Final HCPS Screener_Spanish_ 2023_10072020 Final HCPS Screener_Spanish_10072020.docx	Form
7 V 2023Patient Screener_Vietnamese_10072020.docx 2019 Patient Screener_Vietnamese_10072020.docx	Form
7 V 2023Patient Screener_Vietnamese_10072020.docx 2019 Patient Screener_Vietnamese_10072020.docx	Form
8 Phone Version_Informed Consent Form for Adult Survey Par Phone Version_Informed Consent Form for Adult Survey Participation .docx	Form
8 Phone Version_Informed Consent Form for Adult Survey Par Phone Version_Informed Consent Form for Adult Survey Participation .docx	Form
8 C Phone Version Informed Consent Form for Adult Survey Par Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docx	Form
8 C Phone Version Informed Consent Form for Adult Survey Par Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docx	Form
8 S Phone Version_Informed Consent Form for Adult Survey Par Phone Version_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_11-04-2020.docx	Form
8 S Phone Version_Informed Consent Form for Adult Survey Par Phone Version_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_11-04-2020.docx	Form
8 V Phone Version Informed Consent Form for Adult Survey Par Phone Version Informed Consent Form for Adult Survey Participation VIE.docx	Form
8 V Phone Version Informed Consent Form for Adult Survey Par Phone Version Informed Consent Form for Adult Survey Participation VIE.docx	Form
9 Phone Version_Informed Consent Form for Parent or Guardi Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docx	Form
9 Phone Version_Informed Consent Form for Parent or Guardi Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docx	Form
9 C Phone Version Informed Consent Form for Parent or Guardi Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docx	Form
9 C Phone Version Informed Consent Form for Parent or Guardi Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docx	Form
9 S Phone Version_Informed Consent Form for Parent or Guardi Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_11-04-2020.docx	Form
9 S Phone Version_Informed Consent Form for Parent or Guardi Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_11-04-2020.docx	Form
9 V Phone Version Informed Consent Form for Parent or Guardi Phone Version Informed Consent Form for Parent or Guardian Proxy VIE.docx	Form
9 V Phone Version Informed Consent Form for Parent or Guardi Phone Version Informed Consent Form for Parent or Guardian Proxy VIE.docx	Form
10 Phone Version_Parent or Guardian Permission form for Acc Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docx	Form
10 Phone Version_Parent or Guardian Permission form for Acc Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docx	Form
10 C Phone Version Parent or Guardian Permission form for Ado Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docx	Form
10 C Phone Version Parent or Guardian Permission form for Ado Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docx	Form
10 S Phone_Version_Parent or Guardian Permission form for Ado Phone_Version_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_11-04-2020.docx	Form
10 S Phone_Version_Parent or Guardian Permission form for Ado Phone_Version_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_11-04-2020.docx	Form
10 V Phone Version Parent or Guardian Permission form for Ado Phone Version Parent or Guardian Permission form for Adolescent Final VIE.docx	Form
10 V Phone Version Parent or Guardian Permission form for Ado Phone Version Parent or Guardian Permission form for Adolescent Final VIE.docx	Form
11 Phone Version_Assent Form for Accompanied Adolescent.doc Phone Version_Assent Form for Accompanied Adolescent.docx	Form
11 Phone Version_Assent Form for Accompanied Adolescent.doc Phone Version_Assent Form for Accompanied Adolescent.docx	Form
11 C Phone Version Assent Form for Accompanied Adolescent Fin Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docx	Form
11 C Phone Version Assent Form for Accompanied Adolescent Fin Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docx	Form
11 S Phone Version Assent Form for Accompanied Adolescent rev Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docx	Form
11 S Phone Version Assent Form for Accompanied Adolescent rev Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docx	Form
11 V Phone Version Assent form for Accompanied Adolescent VIE Phone Version Assent form for Accompanied Adolescent VIE.docx	Form
11 V Phone Version Assent form for Accompanied Adolescent VIE Phone Version Assent form for Accompanied Adolescent VIE.docx	Form
HCPS_brochure_10_26_20_GRAY_NoYr.pdf HCPS_brochure_10_26_20_GRAY_NoYr	IC Document
HCPS_brochure_10_26_20_GRAY_NoYr.pdf HCPS_brochure_10_26_20_GRAY_NoYr	IC Document

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