Older Adult Safe Mobility Assessment Tool

Forms and Documents

Document Name	Status
Follow-up Interview Guide Form and Instruction	Modified
Mobility Planning Tool (MPT) Form and Instruction	Modified
Baseline Interview Form and Instruction	Modified
Screener Interview Guide (Acceptance) Form and Instruction	Modified
Initial Screening (Refusal) Form and Instruction	Modified
OAMAT-ATO-08-29-2016.pdf Supplementary Document	2016-09-08
Attach E PIA 2016.pdf Supplementary Document	2016-09-08
Attach C3d NCIPC Research Determination Form_1005 OlderAdult.pdf Supplementary Document	2016-09-08
Attach C3c_Analytic Plan and Illustrative Table Shells_1005 OlderAdult.doc Supplementary Document	2016-09-08
Attach C3b_follow-up Letter.docx Supplementary Document	2016-09-08
Attach C3a_Mobility Planning Tool.pdf Supplementary Document	2016-09-08
Attach C2 IRB Protocol_1005 OlderAdult.pdf Supplementary Document	2016-09-08
Attach C1_IRB approval letter 2016.pdf Supplementary Document	2016-09-08
Attach B1_NonSubs Comment.pdf Supplementary Document	2016-09-08
Attach B_60DyFRN2016.pdf Supplementary Document	2016-09-08
Attach A_Authorizing Legislation_1005 OlderAdult.docx Supplementary Document	2016-09-08
SSB_1005 OlderAdult_Exten ICRO_GB_9216.docx Supporting Statement B	2016-09-08
SSA_1005 OlderAdult_Exten_ICRO_9716.docx Supporting Statement A	2016-09-08

IC Document Collections

IC ID	Document Title	Status
217705	Follow-up Interview Guide Form and Instruction	Modified
217704	Mobility Planning Tool (MPT) Form and Instruction	Modified
217703	Baseline Interview Form and Instruction	Modified
217702	Screener Interview Guide (Acceptance) Form and Instruction	Modified
217699	Initial Screening (Refusal) Form and Instruction	Modified

ICR Details

OMB Control No: 0920-1005	ICR Reference No: 201609-0920-002
Status: Historical Active	Previous ICR Reference No: 201511-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Older Adult Safe Mobility Assessment Tool
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/17/2017
	Date Received in OIRA: 09/13/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2019	24 Months From Approved	02/28/2017
Responses	3,200	0	6,400
Time Burden (Hours)	367	0	734
Cost Burden (Dollars)	0	0	0

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Abstract: CDC requests approval 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:
	81 FR 41303	06/24/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 62907	09/13/2016
Did the Agency receive public comments on this ICR? Yes

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

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

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ICR Summary 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	3,200	6,400	0	-3,200	0	0
Annual Time Burden (Hours)	367	734	0	-367	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden has been reduced because of annualizing over two years.

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Annual Cost to Federal Government: $151,965

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? Yes

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: 09/13/2016

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