Home Hazard Checklist (Post-modification)

Evaluation of the Older Adults Home Modification Grant Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0335 can be found here:

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

Information Collection (IC) Details

IC Title:	Home Hazard Checklist (Post-modification)	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
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

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 %

	Approved	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.