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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 0920-1050 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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	0920-1050	Participant Screener (English Groups)	AttM_ParticipantScreeners.docx	No	Fillable Fileable
Instruction			AttN_PreInterviewGuides.docx	No	Paper Only
Instruction			AttP_ModeratorGuides.docx	No	Paper Only
Other-WORD			AttO_ConsentForms.docx	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 %

	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

Title	Document	Date Uploaded
Request for Approval under the âGeneric Clearance for the Collection of Routine Customer Feedbackâ (OMB Control Number: 0920-1050)	1050 Request_MyMobility Product Testing_8.9.22.docx	08/16/2022
My Mobility Plan (English)	AttA_MyMobility_Plan_English.pdf	08/16/2022
My Mobility Plan Spanish	AttB_MyMobility_Plan_Spanish.pdf	08/16/2022
My Mobility Plan_Tribal	AttC_MyMobility_Plan_Tribal.pdf	08/16/2022
Medicine Fact Sheet (English)	AttD_Medicine_Fact_Sheet_English.pdf	08/16/2022
Medicine Fact Sheet (Spanish)	AttE_Medicine_Fact_Sheet_Spanish.pdf	08/16/2022
Medicine Fact Sheet (Tribal)	AttF_Medicine_Fact_Sheet_Tribal.pdf	08/16/2022
MyMedications List (English)	AttG_MyMedications_List_English.pdf	08/16/2022
MyMedications List (Spanish	AttH_MyMedications_List_Spanish.pdf	08/16/2022
MyMedications LIst (Tribal)	AttI_MyMedications_List_Tribal.pdf	08/16/2022
MyMedications Action Plan (English)	AttJ_MyMedications_Action_Plan_English.pdf	08/16/2022
MyMedications Action Plan (Spanish)	AttK_MyMedications_Action_Plan_Spanish.pdf	08/16/2022
MyMedications Action Plan (Tribal)	AttL_MyMedications_Action_Plan_Tribal.pdf	08/16/2022
My Mobility PIA	My Mobility _PIA.pdf	08/16/2022

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