Home Hazard Checklist (Post-modification)

Evaluation of the Older Adults Home Modification Grant Program

Documents and Forms

Document Name Document Type
Appendix D. Home Hazard Checklist Form_OAHM_Final.docx Other-Home Hazard Checklist (Post-mo
Appendix D. Home Hazard Checklist Form_OAHM_FINAL_SPL.docx Other-Home Hazard Checklist (Post-mo
Appendix D. Home Hazard Checklist_EOAHMP-C2.DRAFT(clean).docx Other-Appendix D. Home Hazard Checkl

Information Collection (IC) Details

IC Title:	Home Hazard Checklist (Post-modification)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Home Hazard Checklist (Post-modification)	Appendix D. Home Hazard Checklist Form_OAHM_Final.docx	No	Paper Only
Other-Home Hazard Checklist (Post-modification)	Appendix D. Home Hazard Checklist Form_OAHM_FINAL_SPL.docx	No	Paper Only
Other-Appendix D. Home Hazard Checklist_EOAHMP-C2.DRAFT(clean)	Appendix D. Home Hazard Checklist_EOAHMP-C2.DRAFT(clean).docx	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,688	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,688	1,688
Annual IC Time Burden (Hours)	709	709
Annual IC Cost Burden (Dollars)	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.