Participant Information Forms

Prevention and Public Health Funds Evidence-Based Falls Prevention Program Information Collection

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0039 can be found here:

Documents and Forms

Document Name Document Type
Participant Information Forms Form and Instruction
Participant Form 0039 Participant-Information-Form (1).pdf Form and Instruction
Participant Form 0039 Participant-Information-Form (1).pdf Form and Instruction
Post Session Survey 0039 Post Session Survey (2).pdf Form and Instruction
Post Session Survey 0039 Post Session Survey (2).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Participant Information Forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	NA	Participant Form	0039 Participant-Information-Form (1).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	NA	Post Session Survey	0039 Post Session Survey (2).pdf		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: 16,728	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16,728	-9,496	26,224
Annual IC Time Burden (Hours)	1,674	-948	2,622
Annual IC Cost Burden (Dollars)	0	0	0

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.