Health Center Patient Survey (HCPS)

ICR 202303-0915-004

OMB: 0915-0368

Federal Form Document

Forms and Documents

Document Name	Status
Form 3 Patient Screening: Short Blessed Scale Form	Modified
Form 2 Site Recruitment and Training Form	Unchanged
Form 1 Awardee Recruitment Form	Modified
Form 6 Health Center Patient Survey Patient Screening Form Form	Modified
Form 4 T Health Center Patient Survey Patient Survey Instrument Form	Modified
OMB Comments on 0915-0368 -Supporting Statement A HCPS EXTENSION - 20221213 Complete.docx Supporting Statement A	2023-03-21
0368 - Supporting Statement B HCPS Renewal - 20221213.docx Supporting Statement B	2023-03-20
Attachment 13 2019 Critical Incident Form_psg.docx Supplementary Document	2023-03-20
Attachment 13 2019 Critical Incident Protocol_In&Out Site.docx Supplementary Document	2023-03-20
Attachment 13_2019 Receptionist Recruitment Script_English.docx Supplementary Document	2023-03-20
Attachment 13 Iinterview Appointment Card English.doc Supplementary Document	2019-12-26
Attachment 13 2019 FI JobAid_Train Receptionists_final.docx Supplementary Document	2023-03-20
Attachment 9 Sampling Strata_final.docx Supplementary Document	2023-03-20
Attachment 8_Survey Methodology and Selection Specification.pdf Supplementary Document	2023-03-20
Attachment 7_Statistical Design Plan.pdf Supplementary Document	2023-03-20
Attachment 6 Analysis Plan Overview_2019_final.docx Supplementary Document	2023-03-20
Attachment 5 2019 RTI Staff Privacy Pledge.docx Supplementary Document	2023-03-20
Attachment 4 TAP_Member_List_2019.xlsx Supplementary Document	2023-03-20
HCPS Round 2 Cognitive Interview Report.docx Supplementary Document	2023-03-20
HCPS Round 1 Cognitive Interview Results_080819.docx Supplementary Document	2023-03-20

IC Document Collections

IC ID	Document Title	Status
239087	Patient Screening: Short Blessed Scale Form	Modified
239085	Site Recruitment and Training Form	Unchanged
239084	Awardee Recruitment Form	Modified
211603	Health Center Patient Survey Patient Screening Form Form	Modified
211602	Health Center Patient Survey Patient Survey Instrument Form	Modified