Baseline Survey

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

Documents and Forms

Document Name Document Type
Baseline Survey Form and Instruction
Baseline survey Att. 1 - Baseline patient survey (1).docx Form and Instruction
Baseline survey Att. 1 - Baseline patient survey (1).docx Form and Instruction

Information Collection (IC) Details

IC Title:	Baseline Survey	Agency IC Tracking Number:	0920-19ARD

Is this a Common Form? No		IC Status: Unchanged

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	none	Baseline survey	Att. 1 - Baseline patient survey (1).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	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.