Information Collection

Mobility Questionnaire

IC 252684 under ICR 202204-0920-005 · OMB 0920-1254.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1254 Mobility Questionnaire	Form and Instruction
0920-1254 Mobility Questionnaire - Data Collection Instruments (co Attachment 3_COPA Data Collection Instruments_combined 07APR2022.pdf	Form and Instruction
0920-1254 Mobility Questionnaire - Data Collection Instruments (co Attachment 3_COPA Data Collection Instruments_combined 07APR2022.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1254

Is this a Common Form? No

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?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1254	Mobility Questionnaire - Data Collection Instruments (combined English/Spanish)	Attachment 3_COPA Data Collection Instruments_combined 07APR2022.pdf	NA	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 3,800

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	3,800	3,800
Annual IC Time Burden (Hours)	633	633
Annual IC Cost Burden (Dollars)	5,381	5,381

Documents for IC

table that charts IC Documents
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.