Older Adult Safe Mobility Assessment Tool

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Mobility Planning Tool (MPT)	Form	Unchanged	Available
Crosswalk OMB#0920_1005.xlsx	Supplementary Document	Uploaded 2015-11-04	Repair queued
Change Request_Memo OMB#0920_1005.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-11-03	Available
Clean SSB_1005 OlderAdult 100215.docx	Supporting Statement B	Uploaded 2015-10-08	Available
Clean SSA_1005 OlderAdult_100215.docx	Supporting Statement A	Uploaded 2015-10-08	Available
Attachment C3d NCIPC Research Determination Form_1005 OlderAdult.pdf	Supplementary Document	Uploaded 2015-07-30	Available
Attachment C3c_Analytic Plan and Illustrative Table Shells_1005 OlderAdult.doc	Supplementary Document	Uploaded 2015-07-30	Available
Attachment C3b_follow-up Letter.docx	Supplementary Document	Uploaded 2015-07-30	Available
Attachment C3a_Mobility Planning Tool.pdf	Supplementary Document	Uploaded 2015-07-30	Available
Attachment C2 IRB Protocol_1005 OlderAdult.pdf	Supplementary Document	Uploaded 2015-07-30	Available
Attachment C1 Battelle IRB approval letter_1005 OlderAdult.pdf	Supplementary Document	Uploaded 2015-07-30	Available
Attachment B 60 Day notice_1005 OlderAdult.pdf	Supplementary Document	Uploaded 2015-07-30	Available
Attachment A_Authorizing Legislation_1005 OlderAdult.docx	Supplementary Document	Uploaded 2015-07-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217705	Follow-up Interview Guide	Other-WORD	Modified
217704	Mobility Planning Tool (MPT)	Form	Unchanged
217703	Baseline Interview	Other-Interview Script	Unchanged
217702	Screener Interview Guide (Acceptance)	Other-WORD	Modified
217699	Initial Screening (Refusal)	Other-Interview Script	Unchanged

ICR Details

OMB Control No: 0920-1005	ICR Reference No: 201511-0920-003
Status: Historical Active	Previous ICR Reference No: 201507-0920-013
Agency/Subagency: HHS/CDC	Agency Tracking No: 16DC
Title: Older Adult Safe Mobility Assessment Tool
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/13/2015
	Date Received in OIRA: 11/12/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2016	10/31/2016	10/31/2016
Responses	6,400	0	6,400
Time Burden (Hours)	734	0	734
Cost Burden (Dollars)	0	0	0

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Abstract: CDC's National Center for Injury Prevention and Control (NCIPC) requests approval for one (1) year, for a reinstatement with change of the previously approved OMB No. 0920-1005 (Exp. Date: 12-31-2014), to evaluate whether the Mobility Planning Tool (MPT) is effective for promoting readiness to adopt mobility-protective behaviors in older adults and assess potential strategies for dissemination of the MPT.

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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:
	80 FR 18848	04/08/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 45977	08/03/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Baseline Interview
Follow-up Interview Guide
Initial Screening (Refusal)
Screener Interview Guide (Acceptance)
Mobility Planning Tool (MPT)	none	MPT

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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	6,400	6,400	0	0	0	0
Annual Time Burden (Hours)	734	734	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $303,931

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: 11/12/2015

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