Information Collection

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

IC 213599 under ICR 201502-0985-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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
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 %

table that charts list of burden
	Requested	Previously Approved
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

table that charts IC Documents
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.