Information Collection

Older Adult Mobility Ride Share (OAMRS)

IC 231946 under ICR 201610-0920-009 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1154 Older Adult Mobility Ride Share (OAMRS)	Form and Instruction
0920-1154 Written Questionnaire Focus Group Attachment B - Written Questionnaire Focus Group_Revised20180618.docx	Form and Instruction
0920-1154 Focus Group Protocol - Users Attachment C - Focus Group Protocol - Users.doc	Form and Instruction
0920-1154 Focus Group Protocol - Non-Users Attachment D - Focus Group Protocol - Non-Users.doc	Form and Instruction
0920-1154 Interview Protocol - Users Attachment E - Interview Protocol - Users_Revised20180618.docx	Form and Instruction
0920-1154 Interview Protocol - Non-Users Attachment F - Interview Protocol - Non-Users_Revised20180618.docx	Form and Instruction
0920-1154 Screener Focus Group Attachment J - Screener Focus Group.docx	Form and Instruction
0920-1154 Screener Telephone Interview Attachment K - Screener Telephone Interview.docx	Form and Instruction
Attachment A - Ride Share Partner Outreach Materials.docx Ride Share Partner Outreach Materials	IC Document
Attachment G - Informed Consent - Focus Group Protocol Users_Non.doc Informed Consent	IC Document
Attachment H - Flyer for Recruitment.docx Flyer for Recruitment	IC Document
Attachment I - Study Description.docx Study Description	IC Document
Attachment L - Communication Materials.docx Communication Materials	IC Document
Attachment M - PIA.PDF PIA	IC Document
Attachment N - IRB Documentation.pdf IRB Documentation	IC Document
GenIC Request Template_Older Adult Mobility Ride Share (OAMRS)_5_1_18_aj.docx GenIC Request Template OAMRS	IC Document
SSA_GenIC_1154_Older Adult Mobility Ride Share_Revised20180618.docx SSA OAMRS	IC Document
SSB_GenIC_1154_Older Adult Mobility Ride Share_5_1_18.docx SSB OAMRS	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Older Adult Mobility Ride Share (OAMRS)

Agency IC Tracking Number:

0920-1154-18AEF

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Electronic Capability
Form and Instruction	0920-1154	Written Questionnaire Focus Group	Attachment B - Written Questionnaire Focus Group_Revised20180618.docx	NA	No	Fillable Fileable
Form and Instruction	0920-1154	Focus Group Protocol - Users	Attachment C - Focus Group Protocol - Users.doc	na	No	Fillable Fileable
Form and Instruction	0920-1154	Focus Group Protocol - Non-Users	Attachment D - Focus Group Protocol - Non-Users.doc	NA	No	Fillable Fileable
Form and Instruction	0920-1154	Interview Protocol - Users	Attachment E - Interview Protocol - Users_Revised20180618.docx	NA	No	Fillable Fileable
Form and Instruction	0920-1154	Interview Protocol - Non-Users	Attachment F - Interview Protocol - Non-Users_Revised20180618.docx	NA	No	Fillable Fileable
Form and Instruction	0920-1154	Screener Focus Group	Attachment J - Screener Focus Group.docx	NA	No	Fillable Fileable
Form and Instruction	0920-1154	Screener Telephone Interview	Attachment K - Screener Telephone Interview.docx	NA	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 535

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	535	535
Annual IC Time Burden (Hours)	190	190
Annual IC Cost Burden (Dollars)	9,786	9,786

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Ride Share Partner Outreach Materials	Attachment A - Ride Share Partner Outreach Materials.docx	06/26/2018
Informed Consent	Attachment G - Informed Consent - Focus Group Protocol Users_Non.doc	06/26/2018
Flyer for Recruitment	Attachment H - Flyer for Recruitment.docx	06/26/2018
Study Description	Attachment I - Study Description.docx	06/26/2018
Communication Materials	Attachment L - Communication Materials.docx	06/26/2018
PIA	Attachment M - PIA.PDF	06/26/2018
IRB Documentation	Attachment N - IRB Documentation.pdf	06/26/2018
GenIC Request Template OAMRS	GenIC Request Template_Older Adult Mobility Ride Share (OAMRS)_5_1_18_aj.docx	06/26/2018
SSA OAMRS	SSA_GenIC_1154_Older Adult Mobility Ride Share_Revised20180618.docx	06/26/2018
SSB OAMRS	SSB_GenIC_1154_Older Adult Mobility Ride Share_5_1_18.docx	06/26/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.