Information Collection

Testing Health Messages in STEADI Oder Adult Fall Pevention Materials Among Caregivers

IC 209309 under ICR 201111-0920-003 · OMB 0920-0572.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix B - Informal Caregiver Recruiting Script.docx	Instruction
Appendix A - Informal Caregiver Discussion Guide.docx	Other-Informal Caregiver Discussion
Appendix C - Formal Caregiver Recruiting Script.docx	Instruction
Appendix D - Formal Caregiver Discussion Guide.docx	Other-Formal Caregiver Discussion Gu
Appendix F - Check for Safety Fact Sheet.pdf	Other-Review materials
Appendix G - Stay Independent.pdf	Other-Review materials
Appendix H - What You Can Do to Prevent Falls.pdf	Other-Review materials
Informed Consent Appendix E - Informed Consent.docx	Form
Appendix I - Burden-Cost Table.xlsx Appendix I - Burden-Cost Table	IC Document
HMTS-ExpeditedReviewForm_Caregivers.pdf HMTS-ExpeditedReviewForm_Caregivers	IC Document
Appendix J - Project Description.docx Appendix J - Project Description	IC Document
Appendix K - List of Appendices.docx Appendix K - List of Appendices	IC Document

IC Title:

Testing Health Messages in STEADI Oder Adult Fall Pevention Materials Among Caregivers

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Appendix B - Informal Caregiver Recruiting Script.docx	Yes	No	Paper Only
Other-Informal Caregiver Discussion Guide			Appendix A - Informal Caregiver Discussion Guide.docx	Yes	No	Paper Only
Instruction			Appendix C - Formal Caregiver Recruiting Script.docx	Yes	No	Paper Only
Other-Formal Caregiver Discussion Guide			Appendix D - Formal Caregiver Discussion Guide.docx	Yes	No	Paper Only
Form	None	Informed Consent	Appendix E - Informed Consent.docx	Yes	No	Paper Only
Other-Review materials			Appendix F - Check for Safety Fact Sheet.pdf	Yes	No	Paper Only
Other-Review materials			Appendix G - Stay Independent.pdf	Yes	No	Paper Only
Other-Review materials			Appendix H - What You Can Do to Prevent Falls.pdf	Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 244

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	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	244	0	0	0	0	0
Annual IC Time Burden (Hours)	128	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix I - Burden-Cost Table	Appendix I - Burden-Cost Table.xlsx	11/07/2013
HMTS-ExpeditedReviewForm_Caregivers	HMTS-ExpeditedReviewForm_Caregivers.pdf	11/07/2013
Appendix J - Project Description	Appendix J - Project Description.docx	11/07/2013
Appendix K - List of Appendices	Appendix K - List of Appendices.docx	11/07/2013

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