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Baseline Interview
Older Adult Safe Mobility Assessment Tool
OMB: 0920-1005
IC ID: 217703
OMB.report
HHS/CDC
OMB 0920-1005
ICR 201609-0920-002
IC 217703
( )
Documents and Forms
Document Name
Document Type
Baseline Interview
Form and Instruction
Baseline Interview
Attach D1 Screener Interviewer guide_1005 OlderAdult_Ext_ICRO_9216.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Baseline Interview
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
none
Baseline Interview
Attach D1 Screener Interviewer guide_1005 OlderAdult_Ext_ICRO_9216.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
09-20-0160 Records of Subjects in Health Promotion and Education Studies
FR Citation:
51 FR 42484
Number of Respondents:
500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
500
0
-500
0
0
1,000
Annual IC Time Burden (Hours)
83
0
-84
0
0
167
Annual IC Cost Burden (Dollars)
0
0
0
0
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.