Information Collection

Prevention and Public Health Funds Evidenced-Based Falls Prevention Program (Individuals)

IC 213597 under ICR 201801-0985-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 2 Prevention and Public Health Funds Evidenced-Based Falls Prevention Program (Individuals)	Form and Instruction
2 Revised Participant Information Resvised Participant-Information-Form - 12.21.17.docx	Form and Instruction
3 Revised Post Session Survey Revised Post Session Survey - 12.21.2017.docx	Form

IC Title:

Prevention and Public Health Funds Evidenced-Based Falls Prevention Program (Individuals)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	2	Revised Participant Information	Resvised Participant-Information-Form - 12.21.17.docx		Yes	Yes	Fillable Fileable
Form	3	Revised Post Session Survey	Revised Post Session Survey - 12.21.2017.docx		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: 26,224

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	26,224	16,224	10,000
Annual IC Time Burden (Hours)	2,622	622	2,000
Annual IC Cost Burden (Dollars)	0	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.