Information Collection

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

IC 209309 under ICR 201501-0920-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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: Unchanged

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
	Requested	Previously Approved
Annual Number of Responses for this IC	244	244
Annual IC Time Burden (Hours)	128	128
Annual IC Cost Burden (Dollars)	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.