Prevention and Public Health Funds Evidence-Based Falls Prevention Program Information Collection

Forms and Documents

Document Name	Status
Form 5 Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Staff Respondents) Form and Instruction	New
Form 1 Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Local Respondents) Form and Instruction	New
Form 2 Prevention and Public Health Funds Evidenced-Based Falls Prevention Program (Individuals) Form and Instruction	New
Falls Supporting_Statement 1-23-15.docx Supporting Statement A	2015-01-26

IC Document Collections

IC ID	Document Title	Status
213600	Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Staff Respondents) Form and Instruction	New
213599	Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Local Respondents) Form and Instruction	New
213597	Prevention and Public Health Funds Evidenced-Based Falls Prevention Program (Individuals) Form and Instruction	New

ICR Details

OMB Control No: 0985-0039	ICR Reference No: 201410-0985-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/ACL	Agency Tracking No:
Title: Prevention and Public Health Funds Evidence-Based Falls Prevention Program Information Collection
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/26/2015
	Date Received in OIRA: 11/10/2014
Terms of Clearance: The Post Program instrument is not approved at this time, although the approved burden estimate includes it. ACL will submit a non-substantive change request, along with Part B of the supporting statement, to justify the Post Program survey prior to its use.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	36 Months From Approved
Responses	10,862	0	0
Time Burden (Hours)	3,044	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Administration on Aging (AoA), Administration for Community Living (ACL), is proposing to use this set of data collection tools to monitor 10 cooperative agreements to states and 4 cooperative agreements to tribal entities that will be awarded in response to the "PPHF-2014-Evidence-Based Falls Prevention Programs financed solely by 2014 Prevention and Public Health Funds (PPHF-2014)" funding opportunity announcement (FOA). The PPHF is accompanied by a high level of transparency, oversight, and accountability. All recipients of PPHF must follow Health and Human Services guidance related to the tracking, monitoring and reporting on the use of PPHF financing. ACL/AoA outlined basic reporting requirements in the Evidence-Based Falls Prevention FOA and will also list these requirements in the Standard Terms and Conditions of grantees' notice of awards. These Terms and Conditions will require each grantee to prepare and submit progress reports to ACL/AoA that will enable the agency to monitor program performance. ACL/AoA will use the information to: 1) Comply with reporting requirements required by the authorizing statues, 2) Collect data for performance measures used in the justification of the budget to Congress and by program, state and national decision makers, 3) Effectively manage the PPHF Falls Prevention program at the federal, state, and local levels, 4) Identify program implementation issues and pinpoint areas for technical assistance activities, 5) Identify best practices in program implementation and building sustainable program delivery systems and to develop resources to enable current and future grantees to learn from and replicate these practices; and 6) Provide information as requested for reports to Congress, other governmental agencies, stakeholders and to the public upon request about PPHF Falls Prevention grantee progress. Data will be collected from project level staff, local community agency staff involved in delivering the evidence-based falls prevention programs, as well as individuals who participate in the falls prevention programs.

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Authorizing Statute(s): PL: Pub.L. 109 - 365 411 Name of Law: Program Authorization
   PL: Pub.L. 109 - 365 206 Name of Law: Evaluation
   PL: Pub.L. 113 - 76 218 Name of Law: Prevention and Public Health Fund Reporting
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 36527	06/27/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 180	09/17/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Prevention and Public Health Funds Evidenced-Based Falls Prevention Program (Individuals)	2, 3	Participant Information ,   Post Session Survey
Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Local Respondents)	1, 2, 4, 3, 6	Falls Program Information Sheet ,   Participant Information ,   Post Session Survey ,   Attendance Log ,   Host Organization
Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Staff Respondents)	5	Falls Performance Report

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	10,862	0	0	10,862	0	0
Annual Time Burden (Hours)	3,044	0	0	3,044	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection that ACL wishes to implement.

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Annual Cost to Federal Government: $116,098

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/10/2014

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