Information Collection

Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Local Respondents)

IC 213599 under ICR 201410-0985-001 · OMB 0985-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0039 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Local Respondents) Form and Instruction
1 Falls Program Information Sheet Attachment_1_Falls_Program-Info-Cover-Sheet.pdf Form and Instruction
2 Participant Information Attachment_2_Participant_Information_Form.pdf Form
3 Post Session Survey Attachment_3_Post_Session_Survey.pdf Form
4 Attendance Log Attachment_4_Attendance_Log.pdf Form
6 Host Organization Attachment_6_Host_Organization_Information_Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Local Respondents)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Falls Program Information Sheet	Attachment_1_Falls_Program-Info-Cover-Sheet.pdf	No		Fillable Fileable
Form	2	Participant Information	Attachment_2_Participant_Information_Form.pdf	Yes	No	Fillable Fileable
Form	3	Post Session Survey	Attachment_3_Post_Session_Survey.pdf	Yes	Yes	Fillable Fileable
Form	4	Attendance Log	Attachment_4_Attendance_Log.pdf	Yes	Yes	Fillable Fileable
Form	6	Host Organization	Attachment_6_Host_Organization_Information_Form.pdf	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 834	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	834	834
Annual IC Time Burden (Hours)	820	820
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.