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Patient Screening: Short Blessed Scale
Health Center Patient Survey (HCPS)
OMB: 0915-0368
IC ID: 239087
OMB.report
HHS/HSA
OMB 0915-0368
ICR 202303-0915-004
IC 239087
( )
Documents and Forms
Document Name
Document Type
Form 3
Patient Screening: Short Blessed Scale
Form
3 Attachment 13 Short Blessed Scale Test_psg.docx
Attachment 13 Short Blessed Scale Test_psg.docx
Form
3 Attachment 13 Short Blessed Scale Test_psg.docx
Attachment 13 Short Blessed Scale Test_psg.docx
Form
3 C Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx
Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx
Form
3 C Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx
Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx
Form
3 S Attachment 13 Short Blessed Scale (Spanish)_psg.docx
Attachment 13 Short Blessed Scale (Spanish)_psg.docx
Form
3 S Attachment 13 Short Blessed Scale (Spanish)_psg.docx
Attachment 13 Short Blessed Scale (Spanish)_psg.docx
Form
3 V Attachment 13 Short Blessed Scale Exam 2023_VIE_psg.docx
Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx
Form
3 V Attachment 13 Short Blessed Scale Exam 2023_VIE_psg.docx
Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx
Form
3 T Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
Form
3 T Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Patient Screening: Short Blessed Scale
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
3
Attachment 13 Short Blessed Scale Test_psg.docx
Attachment 13 Short Blessed Scale Test_psg.docx
Yes
Yes
Fillable Fileable
Form
3 C
Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx
Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx
Yes
Yes
Fillable Fileable
Form
3 S
Attachment 13 Short Blessed Scale (Spanish)_psg.docx
Attachment 13 Short Blessed Scale (Spanish)_psg.docx
Yes
Yes
Fillable Fileable
Form
3 V
Attachment 13 Short Blessed Scale Exam 2023_VIE_psg.docx
Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx
Yes
Yes
Fillable Fileable
Form
3 T
Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
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:
18
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
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
18
0
0
0
0
18
Annual IC Time Burden (Hours)
1
0
0
0
0
1
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.