Information Collection

Falls Diary

IC 228511 under ICR 201709-0920-009 · OMB 0920-1220.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Falls Diary	Form and Instruction
Falls Diary (Calendar and Log) Att B-3. Falls Calendar & Log.docx	Form and Instruction

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:

table that charts list of 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 %

table that charts list of burden
	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

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.