Falls Diary

Test Predictability of Falls Screening Tools

Documents and Forms

Document Name Document Type
Falls Diary Form and Instruction
Falls Diary (Calendar and Log) Att B-3. Falls Calendar & Log.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Falls Diary	Agency IC Tracking Number:	0920-17HO

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Falls Diary (Calendar and Log)	Att B-3. Falls Calendar & Log.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 252

Number of Respondents: 276	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	552	552
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	1,028	1,028

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.