Information Collection

Evidence-Based Falls Prevention Program (Local Respondents)

IC 213599 under ICR 202401-0985-002 · OMB 0985-0039.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Evidence-Based Falls Prevention Program (Local Respondents)	Form and Instruction
Cover Sheet 0039 Program.Info_.Cover_.Sheet.pdf	Form and Instruction
Attendance Log 0039 Falls_Attendance_ Log.pdf	Form and Instruction

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Cover Sheet	0039 Program.Info_.Cover_.Sheet.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	NA	Attendance Log	0039 Falls_Attendance_ Log.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: 480

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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	960	48	912
Annual IC Time Burden (Hours)	960	66	894
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.