Test Predictability of Falls Screening Tools

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Proxy Survey (Phone Mode)	Form and Instruction	New	Available
Proxy Survey Web Mode	Form and Instruction	New	Available
Falls Diary (Calendar and Log)	Form and Instruction	New	Available
Form 0920-17HO Att B-12. Final Survey_CATI_9 26 17	Form and Instruction	New	Available
Form 0920-17HO Att B-11. Falls Final Screenshots	Form and Instruction	New	Available
Form 0920-17HO Att B-10. Monthly Update Survey 09 26 17	Form and Instruction	New	Available
Form 0920-17HO Att B-9. Falls Monthly Survey Screenshots	Form and Instruction	New	Available
Form 0920-17HO Att B-8 Baseline Survey_CATI_09 26 17	Form and Instruction	New	Available
Form 0920-17HO Att B-7. Falls Baseline Screenshots	Form and Instruction	New	Available
Att A-1. PHSA Authorizing Legislation.doc	Supplementary Document	Uploaded 2017-10-02	Available
Att A-2 AmeriSpeak Technical Overview 09 26 17.pdf	Supplementary Document	Uploaded 2017-10-02	Available
Att A-9. IRB Protocol.doc	Supplementary Document	Uploaded 2017-10-02	Available
Att A-8. AmeriSpeak Privacy Statement_Revised09 26 17.pdf	Supplementary Document	Uploaded 2017-10-02	Available
Att A-6. Documentation for AmeriSpeak Panel for IRBs.pdf	Supplementary Document	Uploaded 2017-10-02	Available
Att A-5. PIA Test Predictability of Falls Screening Tool TPFST 3-22-2017 (002).pdf	Supplementary Document	Uploaded 2017-10-02	Available
Att A-7. AmeriSpeak Standard Profile Variables with Values.pdf	Supplementary Document	Uploaded 2017-10-02	Available
Att A-10. IRB Approval.pdf	Supplementary Document	Uploaded 2017-10-02	Available
Att A-11 Research Determination.pdf	Supplementary Document	Uploaded 2017-10-02	Available
Att B-3. Falls Calendar & Log.docx	Supplementary Document	Uploaded 2017-10-02	Available
Att B-4. Cover Letter for Monthly & Diary - Mail.docx	Supplementary Document	Uploaded 2017-10-02	Available
Att B-5. Cover Letter for Monthly & Diary - Email.docx	Supplementary Document	Uploaded 2017-10-02	Available
Att B-6. Proxy Survey Protocol.docx	Supplementary Document	Uploaded 2017-10-02	Available
SSB_17HO_3.06.18.docx	Supporting Statement B	Uploaded 2018-03-06	Available
SSA_17HO_3.06.18.docx	Supporting Statement A	Uploaded 2018-03-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
228549	Proxy Survey Phone Mode	Form and Instruction	New	Proxy Survey (Phone Mode)
228541	Proxy Survey Web Mode	Form and Instruction	New	Proxy Survey Web Mode
228511	Falls Diary	Form and Instruction	New	Falls Diary (Calendar and Log)
228509	Final Survey Phone Mode	Form and Instruction	New	Att B-12. Final Survey_CATI_9 26 17
228503	Final Survey Web Mode	Form and Instruction	New	Att B-11. Falls Final Screenshots
228501	Monthly Update Survey (months 1-11) Phone Mode	Form and Instruction	New	Att B-10. Monthly Update Survey 09 26 17
228500	Monthly Update Survey (Months 1-11) Web Mode	Form and Instruction	New	Att B-9. Falls Monthly Survey Screenshots
228499	Baseline Survey Phone Mode	Form and Instruction	New	Att B-8 Baseline Survey_CATI_09 26 17
228498	Baseline Survey Web Mode	Form and Instruction	New	Att B-7. Falls Baseline Screenshots
228497	Initial Postcard and Email	Instruction	New

ICR Details

OMB Control No: 0920-1220	ICR Reference No: 201709-0920-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-17HO
Title: Test Predictability of Falls Screening Tools
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: 03/08/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/27/2017
Terms of Clearance: Approved consistent with the understanding that CDC/NORC will not use data collected from this study to draw conclusions about the likelihood or prevalence of falls among community living adults over 65.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	24 Months From Approved
Responses	14,745	0	0
Time Burden (Hours)	2,969	0	0
Cost Burden (Dollars)	66,354	0	0

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Abstract: The data collected will be used to screen questions that are clinically useful for quickly sorting patients into risk levels for falls. In this effort, the study will: 1) test the ability of existing falls screening tools Fall screening tools to predict falls in the subsequent year; 2) assess how well questions predict falls for specific groups (e.g., gender, race, disability status); and 3) assess how responses to questions change over time.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

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:
	81 FR 96000	12/29/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 44796	09/26/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Baseline Survey Phone Mode	0920-17HO	Att B-8 Baseline Survey_CATI_09 26 17
Baseline Survey Web Mode	0920-17HO	Att B-7. Falls Baseline Screenshots
Falls Diary	n/a	Falls Diary (Calendar and Log)
Final Survey Phone Mode	0920-17HO	Att B-12. Final Survey_CATI_9 26 17
Final Survey Web Mode	0920-17HO	Att B-11. Falls Final Screenshots
Initial Postcard and Email
Monthly Update Survey (Months 1-11) Web Mode	0920-17HO	Att B-9. Falls Monthly Survey Screenshots
Monthly Update Survey (months 1-11) Phone Mode	0920-17HO	Att B-10. Monthly Update Survey 09 26 17
Proxy Survey Phone Mode	n/a	Proxy Survey (Phone Mode)
Proxy Survey Web Mode	n/a	Proxy Survey Web Mode

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ICR Summary of Burden

table that charts list 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	14,745	0	0	14,745	0	0
Annual Time Burden (Hours)	2,969	0	0	2,969	0	0
Annual Cost Burden (Dollars)	66,354	0	0	66,354	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 data collection. Please note that the 30-day FRN and SS-A.12 provide a total estimated annualized burden of 2,970 hours. ROCIS rounds total estimated annualized burden to 2,969 hours. The 1-hour discrepancy is due to use of different methods of rounding. See the second-to-last line of the burden table (Proxy Survey Web Mode), which the program rounded to 12 and ROCIS rounded to 11.

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Annual Cost to Federal Government: $383,655

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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: 10/27/2017

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