Evaluation of CDC’s STEADI Older Adult Fall Prevention Initiative in a Primary Care Setting

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-19ARD Operations Manager Interivew	Form and Instruction	Unchanged	Repair queued
Provider Interview Guide	Form and Instruction	Unchanged	Available
Form 0920-19ARD Consent Form	Form and Instruction	Unchanged	Repair queued
Follow-up Survey	Form and Instruction	Unchanged	Repair queued
Baseline Survey	Form and Instruction	Unchanged	Repair queued
Change Request OMB-0920-1281 STEADI Cost Effectiveness.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-08-16	Available
Crosswalk OMB#0920_1281.xlsx	Supplementary Document	Uploaded 2020-07-15	Repair queued
Change Request STEADI Cost Effectiveness 7_1_20 .docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-07-15	Repair queued
Final Change Request STEADI Cost Effectiveness 4-7-2020.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-04-09	Repair queued
Att J_ Falls Tracking Log.docx	Supplementary Document	Uploaded 2019-10-16	Repair queued
Att I_ Illustrative table shells.xlsx	Supplementary Document	Uploaded 2019-10-16	Repair queued
Att H_ IRB letter.pdf	Supplementary Document	Uploaded 2019-10-16	Repair queued
Att G Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2019-10-16	Repair queued
Att F _ 60 day FRN STEADI Eval.pdf	Supplementary Document	Uploaded 2019-10-16	Repair queued
Att A_ Authorizing Legislation.docx	Supplementary Document	Uploaded 2019-10-16	Available
SSB STEADI eval primary care _10_9_19.docx	Supporting Statement B	Uploaded 2019-10-16	Repair queued
SSA STEADI eval primary care_ 10_9_19 final.docx	Supporting Statement A	Uploaded 2019-10-16	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
238165	Operations Manager Interivew	Form and Instruction	Unchanged
238164	Provider Interview Guide	Form and Instruction	Unchanged
238163	Consent Form	Form and Instruction	Unchanged
238161	Follow-up Survey	Form and Instruction	Unchanged
238160	Baseline Survey	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-1281	ICR Reference No: 202108-0920-010
Status: Received in OIRA	Previous ICR Reference No: 202007-0920-011
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1281-21HF
Title: Evaluation of CDC’s STEADI Older Adult Fall Prevention Initiative in a Primary Care Setting
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/16/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	01/31/2023	01/31/2023
Responses	4,928	4,928
Time Burden (Hours)	1,174	1,174
Cost Burden (Dollars)	0	0

---

Abstract: This Non-Substantive change request is related to the ICR entitled, “Evaluation of CDC’s STEADI Older Adult Fall Prevention Initiative in a Primary Care Setting,” OMB control number 0920-1281. This Non-Substantive change request is to modify the incentive provided for the baseline and follow-up patient surveys and does not include changes to the currently approved burden and/or costs to the public.

---

Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 24150	05/24/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 57434	10/25/2019
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Baseline Survey	none	Baseline survey
Consent Form	0920-19ARD	Consent Form
Follow-up Survey	none	Follow up survey
Operations Manager Interivew	0920-19ARD	Operations Manager Interview
Provider Interview Guide	none	Provider interview guide

---

ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	4,928	4,928	0	0	0	0
Annual Time Burden (Hours)	1,174	1,174	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $373,562

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/16/2021

---