View Information Collection (IC)
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ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
My Mobility Product Testing Activities
Agency IC Tracking Number:
0920-1050-22IH
IC Status:
New
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
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 %
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
320
0
320
0
0
0
Annual IC Time Burden (Hours)
108
0
108
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (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.
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