View Information Collection (IC)

View Information Collection (IC)

Health Center Patient Survey Patient Screening Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 6 National_Patient Arrival and Referral Tracking Form Final_psg.docx Attachment11 National_Patient Arrival and Referral Tracking Form Final_psg.docx Yes Yes Fillable Fileable
Form 7 Final HCPS Screener_English_09302019_psg.docx Attachment 12 Final HCPS Screener_English_09302019_psg.docx Yes Yes Fillable Fileable
Form 7 C Final HCPS Screener_Chinese_09302019_psg.docx Attachment 12 Final HCPS Screener_Chinese_09302019_psg.docx Yes Yes Fillable Fileable
Form 7 S Final HCPS Screener_Spanish_09302019_psg.docx Attachment 12 Final HCPS Screener_Spanish_09302019_psg.docx Yes Yes Fillable Fileable
Form 7 T Final HCPS Screener_Spanish_09302019_psg.docx Attachment 12 HCPS Patient Screener_Tagalog_psg.docx Yes Yes Fillable Fileable
Form 7 V Final HCPS Screener_Vietnamese_09302019_psg.docx Attachment 12 Final HCPS Screener_Vietnamese_09302019_psg.docx Yes Yes Fillable Fileable
Form 8 Informed Consent Form for Adult Survey Participation reviewed Final_psg.docx Attachment13_Informed Consent Form for Adult Survey Participation reviewed Final_psg.docx Yes Yes Fillable Fileable
Form 8 C Informed Consent Form for Adult Survey Participation Final_TChinese_09272019_clean_psg.docx Attachment 13 Informed Consent Form for Adult Survey Participation Final_TChinese_09272019_clean_psg.docx Yes Yes Fillable Fileable
Form 8 S Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx Attachment13_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx Yes Yes Fillable Fileable
Form 8 T _Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx Attachment 13 Informed Consent Form for Adult Survey Participation Tagalog_psg.docx Yes Yes Fillable Fileable
Form 8 V Informed Consent Form for Adult Survey Participation VIE_09-27-2019_psg.docx Attachment 13 Informed Consent Form for Adult Survey Participation VIE_09-27-2019_psg.docx Yes Yes Fillable Fileable
Form 9 Informed Consent Form for Parent or Guardian Proxy reviewed Final_psg.docx Attachment13_Informed Consent Form for Parent or Guardian Proxy reviewed Final_psg.docx Yes Yes Fillable Fileable
Form 9 C Informed Consent Form for Parent or Guardian Proxy Final_TChinese_09272019_clean_psg.docx Attachment 13 Informed Consent Form for Parent or Guardian Proxy Final_TChinese_09272019_clean_psg.docx Yes Yes Fillable Fileable
Form 9 S Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_09-27-2019_psg.docx Attachment13_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_09-27-2019_psg.docx Yes Yes Fillable Fileable
Form 9 T Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx Attachment 13 Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx Yes Yes Fillable Fileable
Form 9 V Informed Consent Form for Parent or Guardian Proxy VIE_09-27-2019_psg.docx Attachment 13 Informed Consent Form for Parent or Guardian Proxy VIE_09-27-2019_psg.docx Yes Yes Fillable Fileable
Form 10 Parent or Guardian Permission form for Accompanied Adolescent reviewed Final_psg.docx Attachment13_Parent or Guardian Permission form for Accompanied Adolescent reviewed Final_psg.docx Yes Yes Fillable Fileable
Form 10 S Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx Attachment13_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx Yes Yes Fillable Fileable
Form 10 T Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx Attachment 13 Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx Yes Yes Fillable Fileable
Form 10 V Parent or Guardian Permission form for Adolescent Final VIE_09-27-2019_psg.docx Attachment 13 Parent or Guardian Permission form for Adolescent Final VIE_09-27-2019_psg.docx Yes Yes Fillable Fileable
Form 10 C Parent or Guardian Permission form for Adolescent Final_TChinese_09272019_clean_psg.docx Attachment 13 Parent or Guardian Permission form for Adolescent Final_TChinese_09272019_clean_psg.docx Yes Yes Fillable Fileable
Form 11 Assent Form for Accompanied Adolescent reviewed Final_psg.docx Attachment13_Assent Form for Accompanied Adolescent reviewed Final_psg.docx Yes Yes Fillable Fileable
Form 11 C Assent Form for Accompanied Adolescent Final_TChinese_09272019_clean_psg.docx Attachment 13 Assent Form for Accompanied Adolescent Final_TChinese_09272019_clean_psg.docx Yes Yes Fillable Fileable
Form 11 S Assent Form for Accompanied Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx Attachment13_Assent Form for Accompanied Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx Yes Yes Fillable Fileable
Form 11 V Assent form for Accompanied Adolescent VIE_09-27-2019_psg.docx Attachment 13 Assent form for Accompanied Adolescent VIE_09-27-2019_psg.docx Yes Yes Fillable Fileable
Form 12 Contact Summary Report Form Final_psg.docx Attachment 13 Contact Summary Report Form Final_psg.docx Yes Yes Fillable Fileable

Health Health Care Services

 

13,120 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 13,120 0 13,120 0 0 0
Annual IC Time Burden (Hours) 2,230 0 2,230 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment 13 HCPS_brochure_2_4_19_GRAY_NoYr Attachment 13 HCPS_brochure_2_4_19_GRAY_NoYr.pdf 12/26/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.