Health Center Patient Survey

Forms and Documents

Document Name	Status
Form 1 Patient Survey Instrument Form and Instruction	New
Form 1 Patient Screening Form Form	New
Supporting Statement B.docx Supporting Statement B	2013-09-16
Appendix E Critical Incident Form.docx Supplementary Document	2013-04-30
Appendix D Data Security Plan.docx Supplementary Document	2013-04-30
Appendix B 60Day Federal Notice.pdf Supplementary Document	2013-04-30
Appendix C Technical Advisory Committee Members.docx Supplementary Document	2013-04-30
Appendix A - 2006 USC Title 42 Section 254b.pdf Supplementary Document	2013-04-30
OMB_Vietnamese_materials.pdf Supplementary Document	2013-04-30
OMB_Spanish_materials.pdf Supplementary Document	2013-04-30
OMB_Chinese_Materials.pdf Supplementary Document	2013-04-30
OMB_Korean_materials.pdf Supplementary Document	2013-04-30
Incentive Receipt.doc Supplementary Document	2013-05-09
Consent forms (3).doc Supplementary Document	2013-05-09
2014 Health Center Patient Survey Cognitive Protocol Intro.doc Supplementary Document	2013-05-09
Handout_English.doc Supplementary Document	2013-05-09
Flyer.doc Supplementary Document	2013-05-09
Recruitment Script_At Clinic.docx Supplementary Document	2013-05-09
Supporting Statement A.docx Supporting Statement A	2013-05-01

IC Document Collections

IC ID	Document Title	Status
206893	Patient Survey Instrument Form and Instruction	New
206892	Patient Screening Form Form	New

ICR Details

OMB Control No: 0915-0368	ICR Reference No: 201305-0915-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No: 19425
Title: Health Center Patient Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/17/2013
	Date Received in OIRA: 05/13/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved
Responses	161	0	0
Time Burden (Hours)	95	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Health Center Patient Survey 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 cognitive pre-test will refine and test the survey instrument, test the survey sampling methodologies and procedures before it is implemented nationally. The respondents are Health Center patients from different racial/ethnic backgrounds.

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Authorizing Statute(s): US Code: 42 USC 330-331 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 2411	01/11/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 27240	05/09/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Patient Screening Form	1	Patient Screener
Patient Survey Instrument	1	Patient Survey

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	161	0	0	161	0	0
Annual Time Burden (Hours)	95	0	0	95	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection

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Annual Cost to Federal Government: $2,065,959

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/13/2013

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