Screener Interview Guide (Acceptance)

Older Adult Safe Mobility Assessment Tool

Documents and Forms

Document Name Document Type
Screener Interview Guide (Acceptance) Form and Instruction
Baseline Interview Guide Attach D1 Screener Interviewer guide_1005 OlderAdult_Ext_ICRO_9216.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Screener Interview Guide (Acceptance)	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	Baseline Interview Guide	Attach D1 Screener Interviewer guide_1005 OlderAdult_Ext_ICRO_9216.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: 750	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	750	-750	1,500
Annual IC Time Burden (Hours)	63	-62	125
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.