View Information Collection (IC)
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View Information Collection (IC)

Pre-testing for 2019 Health Center Patient Survey (HCPS)
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1E Attachment 1E Patient Screening (English).docx Attachment 7 Patient Screening (English).docx Yes Yes Fillable Fileable
Form and Instruction 1S Attachment 1S Patient Screening (Spanish).docx Attachment 7 Patient Screening (Spanish).docx Yes Yes Fillable Fileable
Form and Instruction 2E Attachment 2E Patient Screening Short Blessed Scale (English).docx Attachment 9 Patient Screening Short Blessed Scale (English).docx Yes Yes Fillable Fileable
Form and Instruction 2S Attachment 2S Patient Screening Short Blessed Scale (Spanish).DOC Attachment 9 Patient Screening Short Blessed Scale (Spanish).DOC Yes Yes Fillable Fileable
Form and Instruction 2V Attachment 2V Patient Screening Short Blessed Scale (Vietnamese).DOCX Attachment 9 Patient Screening Short Blessed Scale (Vietnamese).DOCX Yes Yes Fillable Fileable
Form and Instruction 2C Attachment 2C Patient Screening Short Blessed Scale (Chinese).DOCX Attachment 9 Patient Screening Short Blessed Scale (Chinese).DOCX Yes Yes Fillable Fileable
Form and Instruction 2T Attachment 2T Patient Screening Short Blessed Scale (Tagalog).DOCX Attachment 9 Patient Screening Short Blessed Scale (Tagalog).DOCX Yes Yes Fillable Fileable
Form and Instruction 3E Attachment 3E Patient Survey (English) 06.21.19.docx Attachment 1 Patient Survey (English) 06.21.19.docx Yes Yes Fillable Fileable
Form and Instruction 3S Attachment 3S Patient Survey (Spanish) 06.21.19.docx Attachment 1 Patient Survey (Spanish) 06.21.19.docx Yes Yes Fillable Fileable
Form and Instruction 3V Attachment 3V Patient Survey (Vietnamese) 06.21.19.docx Attachment 1 Patient Survey (Vietnamese) 06.21.19.docx Yes Yes Fillable Fileable
Form and Instruction 3C Attachment 3C Patient Survey (Chinese) 06.21.19.docx Attachment 1 Patient Survey (Chinese) 06.21.19.docx Yes Yes Fillable Fileable
Form and Instruction 3T Attachment 3T Patient Survey (Tagalog) 06.21.19.docx Attachment 1 Patient Survey (Tagalog) 06.21.19.docx Yes Yes Fillable Fileable

Health Health Care Services

 

88 0
   
Individuals or Households
 
   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 88 0 88 0 0 0
Annual IC Time Burden (Hours) 77 0 77 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
0379 - HCPS Supporting Statement A 06.21.19 0379 - HCPS Supporting Statement A 06.21.19.docx 06/25/2019
0379 - HCPS Supporting Statement B 06.21.19 0379 - HCPS Supporting Statement B 06.21.19.docx 06/25/2019
2019 Critical Incident Protocol_Inside&Outide Site 2019 Critical Incident Protocol_Inside&Outide Site.docx 06/25/2019
2019 HCPS Additions and Modifications 2019 HCPS Additions and Modifications.xlsx 06/25/2019
2019 HCPS Additions and Modifications 2019 Respondent Resources List.docx 06/25/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.