Information Collection

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

IC 213599 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⚠️ Notice: This information collection may be referencing outdated material.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 1 Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Local Respondents)	Form and Instruction
1 Falls Program Information Cover Sheet Falls-Program-Info-Cover-Sheet - 12.21.17.docx	Form and Instruction
2 Participant Information Form Resvised Participant-Information-Form - 12.21.17.docx	Form
3 Revised Post Session Survey Revised Post Session Survey - 12.21.2017.docx	Form
4 Attendance Log Falls-Attendance-Log - 9.18.17.docx	Form
5 Host Organization Information Form Host-Organization-Information-Form - 9.18.17.docx	Form

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 Cover Sheet	Falls-Program-Info-Cover-Sheet - 12.21.17.docx	No		Fillable Fileable
Form	2	Participant Information Form	Resvised Participant-Information-Form - 12.21.17.docx	Yes	No	Fillable Fileable
Form	3	Revised Post Session Survey	Revised Post Session Survey - 12.21.2017.docx	Yes	Yes	Fillable Fileable
Form	4	Attendance Log	Falls-Attendance-Log - 9.18.17.docx	Yes	Yes	Fillable Fileable
Form	5	Host Organization Information Form	Host-Organization-Information-Form - 9.18.17.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: 1,436

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
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,436	602	834
Annual IC Time Burden (Hours)	1,434	614	820
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.