Information Collection

My Mobility Product Testing Activities

IC 255311 under ICR 202505-0920-006 · OMB 0920-1050.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1050 can be found here:

2025-06-23 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1050 My Mobility Product Testing Activities	Form and Instruction
Form 0920-1050 Participant Screener (English Groups) My Mobility Product Testing Activities	Form and Instruction
AttN_PreInterviewGuides.docx	Instruction
AttN_PreInterviewGuides.docx	Instruction
AttP_ModeratorGuides.docx	Instruction
AttP_ModeratorGuides.docx	Instruction
AttO_ConsentForms.docx	Other-WORD
AttO_ConsentForms.docx	Other-WORD
0920-1050 Participant Screener (English Groups) AttM_ParticipantScreeners.docx	Form and Instruction
0920-1050 Participant Screener (English Groups) AttM_ParticipantScreeners.docx	Form and Instruction
1050 Request_MyMobility Product Testing_8.9.22.docx Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-105	IC Document
1050 Request_MyMobility Product Testing_8.9.22.docx Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-105	IC Document
AttA_MyMobility_Plan_English.pdf My Mobility Plan (English)	IC Document
AttA_MyMobility_Plan_English.pdf My Mobility Plan (English)	IC Document
AttB_MyMobility_Plan_Spanish.pdf My Mobility Plan Spanish	IC Document
AttB_MyMobility_Plan_Spanish.pdf My Mobility Plan Spanish	IC Document
AttC_MyMobility_Plan_Tribal.pdf My Mobility Plan_Tribal	IC Document
AttC_MyMobility_Plan_Tribal.pdf My Mobility Plan_Tribal	IC Document
AttD_Medicine_Fact_Sheet_English.pdf Medicine Fact Sheet (English)	IC Document
AttD_Medicine_Fact_Sheet_English.pdf Medicine Fact Sheet (English)	IC Document
AttE_Medicine_Fact_Sheet_Spanish.pdf Medicine Fact Sheet (Spanish)	IC Document
AttE_Medicine_Fact_Sheet_Spanish.pdf Medicine Fact Sheet (Spanish)	IC Document
AttF_Medicine_Fact_Sheet_Tribal.pdf Medicine Fact Sheet (Tribal)	IC Document
AttF_Medicine_Fact_Sheet_Tribal.pdf Medicine Fact Sheet (Tribal)	IC Document
AttG_MyMedications_List_English.pdf MyMedications List (English)	IC Document
AttG_MyMedications_List_English.pdf MyMedications List (English)	IC Document
AttH_MyMedications_List_Spanish.pdf MyMedications List (Spanish	IC Document
AttH_MyMedications_List_Spanish.pdf MyMedications List (Spanish	IC Document
AttI_MyMedications_List_Tribal.pdf MyMedications LIst (Tribal)	IC Document
AttI_MyMedications_List_Tribal.pdf MyMedications LIst (Tribal)	IC Document
AttJ_MyMedications_Action_Plan_English.pdf MyMedications Action Plan (English)	IC Document
AttJ_MyMedications_Action_Plan_English.pdf MyMedications Action Plan (English)	IC Document
AttK_MyMedications_Action_Plan_Spanish.pdf MyMedications Action Plan (Spanish)	IC Document
AttK_MyMedications_Action_Plan_Spanish.pdf MyMedications Action Plan (Spanish)	IC Document
AttL_MyMedications_Action_Plan_Tribal.pdf MyMedications Action Plan (Tribal)	IC Document
AttL_MyMedications_Action_Plan_Tribal.pdf MyMedications Action Plan (Tribal)	IC Document
My Mobility _PIA.pdf My Mobility PIA	IC Document
My Mobility _PIA.pdf My Mobility PIA	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

My Mobility Product Testing Activities

Agency IC Tracking Number:

0920-1050-22IH

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form and Instruction	0920-1050	No	Fillable Fileable
Instruction		No	Paper Only
Instruction		No	Paper Only
Other-WORD		No	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 320

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	320	320
Annual IC Time Burden (Hours)	108	108
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval under the âGeneric Clearance for the Collection of Routine Customer Feedbackâ (OMB Control Number: 0920-1050)		08/16/2022
My Mobility Plan (English)		08/16/2022
My Mobility Plan Spanish		08/16/2022
My Mobility Plan_Tribal		08/16/2022
Medicine Fact Sheet (English)		08/16/2022
Medicine Fact Sheet (Spanish)		08/16/2022
Medicine Fact Sheet (Tribal)		08/16/2022
MyMedications List (English)		08/16/2022
MyMedications List (Spanish		08/16/2022
MyMedications LIst (Tribal)		08/16/2022
MyMedications Action Plan (English)		08/16/2022
MyMedications Action Plan (Spanish)		08/16/2022
MyMedications Action Plan (Tribal)		08/16/2022
My Mobility PIA		08/16/2022

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

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