Intercept Consent and Screener

Older Adult Safe Mobility Assessment Tool

OMB: 0920-1005

IC ID: 209374

Documents and Forms
Document Name
Document Type
Other-WORD
Information Collection (IC) Details

View Information Collection (IC)

Intercept Consent and Screener
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-WORD Att F_ IR Consent and Screener_tfs4.docx No No Fillable Printable

Health Health Care Services

 

40 0
   
Individuals or Households
 
   0 %

  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 40 0 40 0 0 0
Annual IC Time Burden (Hours) 10 0 10 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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