Baseline Interview

Older Adult Safe Mobility Assessment Tool

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Baseline Interview	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	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: 500	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	500	-500	1,000
Annual IC Time Burden (Hours)	83	-84	167
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.