Falls Prevention NonSubstantive

Administration on Aging, Administration for Community Living,

U.S. Department of Health and Human Services

January 28, 2015

Evidence-Based Falls Prevention Program Standardized Data Collection

Request for a Non-Substantive Change

On January 26, 2015, The Administration on Aging (AoA), Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) received a Notice of Office of Management and Budget Action approving the following Falls Prevention Data Collection Tools (OMB Control Number: 0985-0039):

• Semi-annual Performance Report

• Host Organization Information Form

• Program Information Cover Sheet

• Attendance Log

• Participant Information Form

In addition to these approved forms, we would like to request clearance to administer a Post Program Survey form.

This form will be completed by each participant at the last session of the program series on a voluntary basis. The Post Program Survey form supplements the Participant Information Form which documents demographic and health characteristics and also assesses some key falls risks and outcome variables. The Post form will provide information about participants’ change in falls risks and about stated program outcomes, including falls self-efficacy, falls and injury rates, fear of falling, and interference with social activities.

Collecting this post information about risk factors and outcomes will provide critical performance information for this particular grant program and help us document that we are achieving the grant goal to “Significantly increase the number of older adults and adults with disabilities at risk of falls who participate in programs to reduce falls and falls risks.” Please see our submitted Part B: Collection of Information Employing Statistical Methods for additional information.