Information Collection

Health Center Patient Survey Patient Screening Form

IC 211603 under ICR 202303-0915-004 · OMB 0915-0368.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 6 Health Center Patient Survey Patient Screening Form	Form
Form 6 National_Patient Arrival and Referral Tracking Form Final_psg.docx Health Center Patient Survey Patient Screening Form	Form
Form 7 T Final HCPS Screener Tagalog_09302019_psg.docx Health Center Patient Survey Patient Screening Form	Form
Form 8 T _Informed Consent Form for Adult Survey Participation reviewed Final Tagalog_09-27-2019_psg.docx Health Center Patient Survey Patient Screening Form	Form
Form 9 T Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx Health Center Patient Survey Patient Screening Form	Form
Form 10 T Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx Health Center Patient Survey Patient Screening Form	Form
Form 12 Contact Summary Report Form Final_psg.docx Health Center Patient Survey Patient Screening Form	Form
Form 7 2023 HCPS Patient Screener ENGLISH Health Center Patient Survey Patient Screening Form	Form
Form 7 C Final HCPS Screener_Chinese_2023_For Revisions.docx Health Center Patient Survey Patient Screening Form	Form
Form 7 S Final HCPS Screener_Spanish_ 2023_10072020 Health Center Patient Survey Patient Screening Form	Form
Form 7 V 2023Patient Screener_Vietnamese_10072020.docx Health Center Patient Survey Patient Screening Form	Form
Form 8 Phone Version_Informed Consent Form for Adult Survey Participation .docx Health Center Patient Survey Patient Screening Form	Form
Form 8 C Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docx Health Center Patient Survey Patient Screening Form	Form
Form 8 S Phone Version_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_11-04-2020.docx Health Center Patient Survey Patient Screening Form	Form
Form 8 V Phone Version Informed Consent Form for Adult Survey Participation VIE.docx Health Center Patient Survey Patient Screening Form	Form
Form 9 Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docx Health Center Patient Survey Patient Screening Form	Form
Form 9 C Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docx Health Center Patient Survey Patient Screening Form	Form
Form 9 S Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_11-04-2020.docx Health Center Patient Survey Patient Screening Form	Form
Form 9 V Phone Version Informed Consent Form for Parent or Guardian Proxy VIE.docx Health Center Patient Survey Patient Screening Form	Form
Form 10 Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docx Health Center Patient Survey Patient Screening Form	Form
Form 10 C Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docx Health Center Patient Survey Patient Screening Form	Form
Form 10 S Phone_Version_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_11-04-2020.docx Health Center Patient Survey Patient Screening Form	Form
Form 10 V Phone Version Parent or Guardian Permission form for Adolescent Final VIE.docx Health Center Patient Survey Patient Screening Form	Form
Form 11 Phone Version_Assent Form for Accompanied Adolescent.docx Health Center Patient Survey Patient Screening Form	Form
Form 11 C Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docx Health Center Patient Survey Patient Screening Form	Form
Form 11 S Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docx Health Center Patient Survey Patient Screening Form	Form
Form 11 V Phone Version Assent form for Accompanied Adolescent VIE.docx 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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Health Center Patient Survey Patient Screening Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	6	Yes	Yes	Fillable Fileable
Form	7 T	Yes	Yes	Fillable Fileable
Form	8 T	Yes	Yes	Fillable Fileable
Form	9 T	Yes	Yes	Fillable Fileable
Form	10 T	Yes	Yes	Fillable Fileable
Form	12	Yes	Yes	Fillable Fileable
Form	7	Yes	Yes	Fillable Fileable
Form	7 C	Yes	Yes	Fillable Fileable
Form	7 S	Yes	Yes	Fillable Fileable
Form	7 V	Yes	Yes	Fillable Fileable
Form	8	Yes	Yes	Fillable Fileable
Form	8 C	Yes	Yes	Fillable Fileable
Form	8 S	Yes	Yes	Fillable Fileable
Form	8 V	Yes	Yes	Fillable Fileable
Form	9	Yes	Yes	Fillable Fileable
Form	9 C	Yes	Yes	Fillable Fileable
Form	9 S	Yes	Yes	Fillable Fileable
Form	9 V	Yes	Yes	Fillable Fileable
Form	10	Yes	Yes	Fillable Fileable
Form	10 C	Yes	Yes	Fillable Fileable
Form	10 S	Yes	Yes	Fillable Fileable
Form	10 V	Yes	Yes	Fillable Fileable
Form	11	Yes	Yes	Fillable Fileable
Form	11 C	Yes	Yes	Fillable Fileable
Form	11 S	Yes	Yes	Fillable Fileable
Form	11 V	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,120

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	13,120	13,120
Annual IC Time Burden (Hours)	2,230	2,230
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HCPS_brochure_10_26_20_GRAY_NoYr		12/11/2020

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

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