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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Health Center Patient Survey Patient Survey Instrument
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
4 T
HCPS Questionnaire_Tagalog_09302019_psg.docx
Attachment 1 HCPS Questionnaire_Tagalog_09302019_psg.docx
Yes
Yes
Fillable Fileable
Form
5
Incentive Receipt (English)_psg.docx
Attachment 13 Incentive Receipt (English)_psg.docx
Yes
Yes
Fillable Fileable
Form
5 C
Incentive Receipt_TChinese_psg.docx
Attachment 13 Incentive Receipt_TChinese_psg.docx
Yes
Yes
Fillable Fileable
Form
5 S
Incentive Receipt_SPA_rev_psg.docx
Attachment 13 Incentive Receipt_SPA_rev_psg.docx
Yes
Yes
Fillable Fileable
Form
5 V
Incentive Receipt_Vietnamese_psg.docx
Attachment 13 Incentive Receipt_Vietnamese_psg.docx
Yes
Yes
Fillable Fileable
Form
5 T
Incentive Receipt Tagalog_psg.docx
Attachment 13 Incentive Receipt Tagalog_psg.docx
Yes
Yes
Fillable Fileable
Form
4
2019 HCPS Questionnaire_ENGLISH
2019 HCPS Questionnaire_MASTER FILE_10072020.docx
Yes
Yes
Fillable Fileable
Form
4 C
Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx
Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx
Yes
Yes
Fillable Fileable
Form
4 S
Final HCPS Questionnaire_Spanish_10072020.docx
Final HCPS Questionnaire_Spanish_10072020.docx
Yes
Yes
Fillable Fileable
Form
4 V
2019 HCPS Questionnaire_Vietnamese_10072020.
2019 HCPS Questionnaire_Vietnamese_10072020.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
9,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
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
9,000
0
0
0
0
9,000
Annual IC Time Burden (Hours)
9,000
0
0
0
0
9,000
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
HCPS Round One Cognitive Interview Results
HCPS Round 1 Cognitive Interview Results_080819.docx
03/17/2023
HCPS Round 2 Report
HCPS Round 2 Cognitive Interview Report.docx
03/17/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.