Follow-up Interview Guide

Older Adult Safe Mobility Assessment Tool

Documents and Forms

Document Name Document Type
Follow-up Interview Guide Form and Instruction
Follow-up Interview Guide Attach D2 Follow Up Interviewer Guide_1005 OlderAdult_Ext.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Follow-up Interview Guide	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	Follow-up Interview Guide	Attach D2 Follow Up Interviewer Guide_1005 OlderAdult_Ext.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

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: 450	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	450	-450	900
Annual IC Time Burden (Hours)	75	-75	150
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.