Mobility Planning Tool (MPT)

Older Adult Safe Mobility Assessment Tool

Documents and Forms

Document Name Document Type
Mobility Planning Tool (MPT) Form and Instruction
Mobility Planning Tool Attach D3 Mobility Planning Tool (MPT).doc Form and Instruction

Information Collection (IC) Details

IC Title:	Mobility Planning Tool (MPT)	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	Mobility Planning Tool	Attach D3 Mobility Planning Tool (MPT).doc		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: 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	250	-250	500
Annual IC Time Burden (Hours)	125	-125	250
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.