Information Collection

Older Adult Mobility Planning Brochure

IC 229714 under ICR 201502-0920-001 · OMB 0920-0572.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.