Health Center Patient Survey (HCPS)

OMB 0915-0368

The HCPS will gather information that will assist policymakers’ assessment of how well HRSA supported health centers are able to meet health care needs and complement data that are not routinely collected from other HRSA data sources. The respondents are health center patients. Interviews are estimated to take approximately 60 minutes.

The latest form for Health Center Patient Survey (HCPS) expires 2023-03-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 3 Patient Screening: Short Blessed Scale Form
Form 2 Site Recruitment and Training Form
Form 1 Awardee Recruitment Form
Form 6 Health Center Patient Survey Patient Screening Form Form
Form 4 T Health Center Patient Survey Patient Survey Instrument Form
OMB Comments on 0915-0368 -Supporting Statement A HCPS EXTENSION - 20221213 Complete.docx Supporting Statement A
0368 - Supporting Statement B HCPS Renewal - 20221213.docx Supporting Statement B
Attachment 13 2019 Critical Incident Form_psg.docx Supplementary Document
Attachment 13 2019 Critical Incident Protocol_In&Out Site.docx Supplementary Document
Attachment 13_2019 Receptionist Recruitment Script_English.docx Supplementary Document
Attachment 13 Iinterview Appointment Card English.doc Supplementary Document
Attachment 13 2019 FI JobAid_Train Receptionists_final.docx Supplementary Document
Attachment 9 Sampling Strata_final.docx Supplementary Document
Attachment 8_Survey Methodology and Selection Specification.pdf Supplementary Document
Attachment 7_Statistical Design Plan.pdf Supplementary Document
Attachment 6 Analysis Plan Overview_2019_final.docx Supplementary Document
Attachment 5 2019 RTI Staff Privacy Pledge.docx Supplementary Document
Attachment 4 TAP_Member_List_2019.xlsx Supplementary Document
HCPS Round 2 Cognitive Interview Report.docx Supplementary Document
HCPS Round 1 Cognitive Interview Results_080819.docx Supplementary Document
Patient Screening: Short Blessed Scale Form
Site Recruitment and Training Form
Awardee Recruitment Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Survey Instrument Form

All Historical Document Collections

202303-0915-004 Approved without change	Extension without change of a currently approved collection	2023-03-22
202012-0915-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-12-14
201912-0915-001 Approved with change	Reinstatement without change of a previously approved collection	2019-12-26
201404-0915-008 Approved with change	Revision of a currently approved collection	2014-05-27
201305-0915-003 Approved with change	New collection (Request for a new OMB Control Number)	2013-05-13

OMB Details

Health Center Patient Survey Patient Survey Instrument

Federal Enterprise Architecture: Health - Health Care Services

Form 5 C	Incentive Receipt_TChinese_psg.docx	Fillable Fileable	Form
Form 4 V	2019 HCPS Questionnaire_Vietnamese_10072020.	Fillable Fileable	Form
Form 4 S	Final HCPS Questionnaire_Spanish_10072020.docx	Fillable Fileable	Form
Form 4	2019 HCPS Questionnaire_ENGLISH	Fillable Fileable	Form
Form 4 C	Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx	Fillable Fileable	Form
Form 5 T	Incentive Receipt Tagalog_psg.docx	Fillable Fileable	Form
Form 5 V	Incentive Receipt_Vietnamese_psg.docx	Fillable Fileable	Form
Form 5 S	Incentive Receipt_SPA_rev_psg.docx	Fillable Fileable	Form
Form 5	Incentive Receipt (English)_psg.docx	Fillable Fileable	Form
Form 4 T	HCPS Questionnaire_Tagalog_09302019_psg.docx	Fillable Fileable	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.