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Intercept Interview Guide
Older Adult Safe Mobility Assessment Tool
OMB: 0920-1005
IC ID: 209377
OMB.report
HHS/CDC
OMB 0920-1005
ICR 201311-0920-013
IC 209377
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1005 can be found here:
2016-09-13 - Extension without change of a currently approved collection
2015-11-12 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Att I- Intercept Interview Guide.docx
Other-WORD
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Intercept Interview Guide
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Other-WORD
Att I- Intercept Interview Guide.docx
No
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
40
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
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)
20
0
20
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.