OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Health Center Patient Survey (HCPS)

OMB 0915-0368 · HHS/HSA.

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 is listed under ICR 202012-0915-002.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 3 T Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docxForm
Form 3 V Attachment 13 Short Blessed Scale Exam 2023_VIE_psg.docxForm
Form 3 S Attachment 13 Short Blessed Scale (Spanish)_psg.docxForm
Form 3 C Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docxForm
Form 3 Attachment 13 Short Blessed Scale Test_psg.docxForm
Form 3 Patient Screening: Short Blessed ScaleForm
Form 2 Attachment10 National_Awardee and Site Recruitment Materials_3-23-20Form
Form 2 Site Recruitment and TrainingForm
Form 1 Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docxForm
Form 1 Awardee RecruitmentForm
Form 11 V Phone Version Assent form for Accompanied Adolescent VIE.docxForm
Form 11 S Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docxForm
Form 11 C Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docxForm
Form 11 Phone Version_Assent Form for Accompanied Adolescent.docxForm
Form 10 V Phone Version Parent or Guardian Permission form for Adolescent Final VIE.docxForm
Form 10 S Phone_Version_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_11-04-2020.docxForm
Form 10 C Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docxForm
Form 10 Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docxForm
Form 9 V Phone Version Informed Consent Form for Parent or Guardian Proxy VIE.docxForm
Form 9 S Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_11-04-2020.docxForm
Form 9 C Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docxForm
Form 9 Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docxForm
Form 8 V Phone Version Informed Consent Form for Adult Survey Participation VIE.docxForm
Form 8 S Phone Version_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_11-04-2020.docxForm
Form 8 C Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docxForm
Form 8 Phone Version_Informed Consent Form for Adult Survey Participation .docxForm
Form 7 V 2023Patient Screener_Vietnamese_10072020.docxForm
Form 7 S Final HCPS Screener_Spanish_ 2023_10072020Form
Form 7 C Final HCPS Screener_Chinese_2023_For Revisions.docxForm
Form 7 2023 HCPS Patient Screener ENGLISHForm
Form 12 Contact Summary Report Form Final_psg.docxForm
Form 10 T Parent or Guardian Permission Form for Adolescent Tagalog_psg.docxForm
Form 9 T Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docxForm
Form 8 T _Informed Consent Form for Adult Survey Participation reviewed Final Tagalog_09-27-2019_psg.docxForm
Form 7 T Final HCPS Screener Tagalog_09302019_psg.docxForm
Form 6 National_Patient Arrival and Referral Tracking Form Final_psg.docxForm
Form 6 Health Center Patient Survey Patient Screening FormForm
Form 4 V 2019 HCPS Questionnaire_Vietnamese_10072020.Form
Form 4 S Final HCPS Questionnaire_Spanish_10072020.docxForm
Form 4 C Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docxForm
Form 4 2019 HCPS Questionnaire_ENGLISHForm
Form 5 T Incentive Receipt Tagalog_psg.docxForm
Form 5 V Incentive Receipt_Vietnamese_psg.docxForm
Form 5 S Incentive Receipt_SPA_rev_psg.docxForm
Form 5 C Incentive Receipt_TChinese_psg.docxForm
Form 5 Incentive Receipt (English)_psg.docxForm
Form 4 T HCPS Questionnaire_Tagalog_09302019_psg.docxForm
Form 4 T Health Center Patient Survey Patient Survey InstrumentForm
OMB Comments on 0915-0368 -Supporting Statement A HCPS EXTENSION - 20221213 Complete.docx (document unavailable)Supporting Statement A
0368 - Supporting Statement B HCPS Renewal - 20221213.docxSupporting 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
Patient Screening: Short Blessed Scale Form
Patient Screening: Short Blessed Scale Form
Patient Screening: Short Blessed Scale Form
Patient Screening: Short Blessed Scale Form
Patient Screening: Short Blessed Scale Form
Site Recruitment and Training Form
Site Recruitment and Training Form
Awardee Recruitment Form
Awardee Recruitment Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Screening Form Form
Health Center Patient Survey Patient Survey Instrument Form
Health Center Patient Survey Patient Survey Instrument Form
Health Center Patient Survey Patient Survey Instrument Form
Health Center Patient Survey Patient Survey Instrument Form
Health Center Patient Survey Patient Survey Instrument Form
Health Center Patient Survey Patient Survey Instrument Form
Health Center Patient Survey Patient Survey Instrument Form
Health Center Patient Survey Patient Survey Instrument Form
Health Center Patient Survey Patient Survey Instrument Form
Health Center Patient Survey Patient Survey Instrument Form
Health Center Patient Survey Patient Survey Instrument Form

All Historical Document Collections

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

OMB Details

Health Center Patient Survey Patient Survey Instrument

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
FormNameElectronic accessType
Form 5 CIncentive Receipt_TChinese_psg.docx Fillable FileableForm
Form 4 V2019 HCPS Questionnaire_Vietnamese_10072020.Fillable FileableForm
Form 4 SFinal HCPS Questionnaire_Spanish_10072020.docx Fillable FileableForm
Form 42019 HCPS Questionnaire_ENGLISHFillable FileableForm
Form 4 CFinal HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx Fillable FileableForm
Form 5 TIncentive Receipt Tagalog_psg.docx Fillable FileableForm
Form 5 VIncentive Receipt_Vietnamese_psg.docx Fillable FileableForm
Form 5 SIncentive Receipt_SPA_rev_psg.docx Fillable FileableForm
Form 5Incentive Receipt (English)_psg.docx Fillable FileableForm
Form 4 THCPS Questionnaire_Tagalog_09302019_psg.docx Fillable FileableForm

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