Information Collection

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

IC 213600 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⚠️ Notice: This information collection may be referencing outdated material.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 5 Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Staff Respondents)	Form and Instruction
5 Falls Semi-Annual Progress Report and Template Instructi Falls-Semi-Annual-Progress-Report-and-Template-Instructions - 9.18.17.docx	Form and Instruction

IC Title:

Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Staff 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5	Falls Semi-Annual Progress Report and Template Instructions	Falls-Semi-Annual-Progress-Report-and-Template-Instructions - 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: 18

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: 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	36	8	28
Annual IC Time Burden (Hours)	288	64	224
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.