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.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
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 (document unavailable)	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All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
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
Form	Name	Electronic access	Type
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.