Older Adult Mobility Planning Brochure

CDC and ATSDR Health Message Testing System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Document Name Document Type
Att E_Confirmatory Letter.pdf Instruction
Att F_Focus Group M Guide.docx Other-Focus Group Guide
Participant Screener Att C_Participant Screener_v2.docx Form and Instruction
HMTSExpeditedReviewForm Mobility Planning Tool.pdf HMTS Expedited Review Form IC Document
Att A_My Mobility brochure.pdf My Mobility Brochure IC Document
Att. B. Project Description.docx Project Description IC Document
Att D_Consent Form_rev.docx Consent IC Document

Information Collection (IC) Details

IC Title:	Older Adult Mobility Planning Brochure	Agency IC Tracking Number:	0920-0572-18GR

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Att E_Confirmatory Letter.pdf	Yes	No	Paper Only
Other-Focus Group Guide			Att F_Focus Group M Guide.docx	Yes	No	Paper Only
Form and Instruction	none	Participant Screener	Att C_Participant Screener_v2.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	106	106
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HMTS Expedited Review Form	HMTSExpeditedReviewForm Mobility Planning Tool.pdf	01/11/2018
My Mobility Brochure	Att A_My Mobility brochure.pdf	01/11/2018
Project Description	Att. B. Project Description.docx	01/11/2018
Consent	Att D_Consent Form_rev.docx	01/11/2018

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