Older Adult Safe Mobility Assessment Tool

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
SupSta B.docx	Supporting Statement B	Uploaded 2013-11-15	Available
Att M - IRB approval.pdf	Supplementary Document	Uploaded 2013-11-15	Available
Att L- Tool Version B.pdf	Supplementary Document	Uploaded 2013-11-15	Available
Att K- Tool VersionA.pdf	Supplementary Document	Uploaded 2013-11-15	Available
Att C- Phase 1 Report.pdf	Supplementary Document	Uploaded 2013-11-15	Available
Att B.2 - Public Comment.docx	Supplementary Document	Uploaded 2013-11-15	Available
Att B.1 - Published 60dy FRN.pdf	Supplementary Document	Uploaded 2013-11-15	Available
Att A - Authorizing Legislation.doc	Supplementary Document	Uploaded 2013-11-15	Available
SupSta A.docx	Supporting Statement A	Uploaded 2013-11-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209378	Telephone Survey	Other-WORD	New
209377	Intercept Interview Guide	Other-WORD	New
209376	Focus Group Moderator Guide	Other-WORD	New
209375	Telephone Survey Consent and Screener	Other-WORD	New
209374	Intercept Consent and Screener	Other-WORD	New
209373	Focus Group Consent & Screener	Other-WORD	New
209372	Key Informant Consent and Interview Guide	Other-WORD	New

ICR Details

OMB Control No: 0920-1005	ICR Reference No: 201311-0920-013
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 20972
Title: Older Adult Safe Mobility Assessment Tool
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 without change	Conclusion Date: 12/30/2013
	Date Received in OIRA: 11/19/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	12 Months From Approved
Responses	2,114	0	0
Time Burden (Hours)	765	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Older Adult Safe Mobility Assessment Tool project involves developing, refining and validating a Safe Mobility Assessment Tool that allows older adults to assess their current mobility situation, learn about mobility challenges that may affect them in the future, and receive actionable feedback on how to improve and protect their mobility. The information collected in this project will be used to refine and improve the Tool, as well as to conduct feasibility and audience acceptability analysis of the Tool. This information will allow CDC to create the most useful Safe Mobility Assessment Tool possible for U.S. older adults.

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Authorizing Statute(s): US Code: 42 USC 241 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 22884	04/17/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 220	11/14/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Key Informant Consent and Interview Guide
Focus Group Consent & Screener
Intercept Consent and Screener
Telephone Survey Consent and Screener
Focus Group Moderator Guide
Intercept Interview Guide
Telephone Survey

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ICR Summary of Burden

table that charts list 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	2,114	0	0	2,114	0	0
Annual Time Burden (Hours)	765	0	0	765	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 collection request for a new OMB control number.

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Annual Cost to Federal Government: $138,700

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 11/19/2013

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