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

Forms and Documents

Document Name	Status
Form 0920-19ARD Operations Manager Interivew Form and Instruction	Unchanged
Provider Interview Guide Form and Instruction	Modified
Form 0920-19ARD Consent Form Form and Instruction	Unchanged
Follow-up Survey Form and Instruction	Unchanged
Baseline Survey Form and Instruction	Unchanged
Change Request for OMB no. 0920-1281_02102022.docx Justification for No Material/Nonsubstantive Change	2022-02-10
Change Request OMB-0920-1281 STEADI Cost Effectiveness.docx Justification for No Material/Nonsubstantive Change	2021-08-16
Crosswalk OMB#0920_1281.xlsx Supplementary Document	2020-07-15
Change Request STEADI Cost Effectiveness 7_1_20 .docx Justification for No Material/Nonsubstantive Change	2020-07-15
Final Change Request STEADI Cost Effectiveness 4-7-2020.docx Justification for No Material/Nonsubstantive Change	2020-04-09
Att J_ Falls Tracking Log.docx Supplementary Document	2019-10-16
Att I_ Illustrative table shells.xlsx Supplementary Document	2019-10-16
Att H_ IRB letter.pdf Supplementary Document	2019-10-16
Att G Privacy Impact Assessment.pdf Supplementary Document	2019-10-16
Att F _ 60 day FRN STEADI Eval.pdf Supplementary Document	2019-10-16
Att A_ Authorizing Legislation.docx Supplementary Document	2019-10-16
SSB STEADI eval primary care _10_9_19.docx Supporting Statement B	2019-10-16
SSA STEADI eval primary care_ 10_9_19 final.docx Supporting Statement A	2019-10-16

IC Document Collections

IC ID	Document Title	Status
238165	Operations Manager Interivew Form and Instruction	Unchanged
238164	Provider Interview Guide Form and Instruction	Modified
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: 202202-0920-003
Status: Received in OIRA	Previous ICR Reference No: 202108-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1281
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: 02/11/2022

	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 to add an incentive for physicians to participate in qualitative interviews and does not include changes to the currently approved burden and/or costs to the public. CDC is also correcting a typographical error in the burden advisory statement on this form.

---

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

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

	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: 02/11/2022

---