Initial Screening (Refusal)

Older Adult Safe Mobility Assessment Tool

Documents and Forms

Document Name Document Type
Initial Screening (Refusal) Form and Instruction
Interview Screener - Refusal Attach D Screener Interviewer Refusing.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Initial Screening (Refusal)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Form and Instruction	none	Interview Screener - Refusal	Attach D Screener Interviewer Refusing.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies	FR Citation: 51 FR 42484

Number of Respondents: 1,250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,250	-1,250	2,500
Annual IC Time Burden (Hours)	21	-21	42
Annual IC Cost Burden (Dollars)	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.