Information Collection

Disability/Mobility Testing Instrument

IC 189765 under ICR 200902-0920-005 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form unnumbered Disability/Mobility Testing Instrument	Form
unnumbered Disability testing form QDRL OMB-10-day letter-Mobility-ImpairedAtt 2.doc	Form
QDRL OMB-10-day letter-Mobility-Impaired060909.doc 10-day letter request	IC Document
QDRL OMB-10-day letter-Mobility-ImpairedAtt 1.doc advertisement	IC Document

IC Title:

Disability/Mobility Testing Instrument

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	unnumbered	Disability testing form	QDRL OMB-10-day letter-Mobility-ImpairedAtt 2.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population

FR Citation: 49 FR 37693

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	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	30	0	0	0	0	0
Annual IC Time Burden (Hours)	30	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
10-day letter request	QDRL OMB-10-day letter-Mobility-Impaired060909.doc	06/15/2009
advertisement	QDRL OMB-10-day letter-Mobility-ImpairedAtt 1.doc	06/15/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.