Information Collection

Evidence-Based Falls Prevention Program (Local Respondents)

IC 213599 under ICR 202103-0985-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Evidence-Based Falls Prevention Program (Local Respondents) Form and Instruction
Cover Sheet 0039 Program.Info_.Cover_.Sheet (3).pdf Form and Instruction
Cover Sheet 0039 Program.Info_.Cover_.Sheet (3).pdf Form and Instruction
Participant Information Form 0039 Participant-Information-Form (1).pdf Form and Instruction
Participant Information 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
Attendance Log 0039 Falls.Attendance.Log (4).pdf Form and Instruction
Attendance Log 0039 Falls.Attendance.Log (4).pdf Form and Instruction
Host Information Form 0039 Falls-Host-Info-Form (5).pdf Form and Instruction
Host Information Form 0039 Falls-Host-Info-Form (5).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Cover Sheet	0039 Program.Info_.Cover_.Sheet (3).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Participant Information 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
Form and Instruction	NA	Attendance Log	0039 Falls.Attendance.Log (4).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Host Information Form	0039 Falls-Host-Info-Form (5).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: 912	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: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	912	-524	1,436
Annual IC Time Burden (Hours)	894	-540	1,434
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.