Evidence-Based Falls Prevention Program (Project Staff)

Prevention and Public Health Funds Evidence-Based Falls Prevention Program Information Collection

Documents and Forms

Document Name Document Type
Evidence-Based Falls Prevention Program (Project Staff) Form and Instruction
Information Cover Sheet 0039 Program.Info_.Cover_.Sheet.pdf Form and Instruction
Attendance Log 0039 Falls_Attendance_ Log.pdf Form and Instruction
Participant Information Form 0039 Participant-Information-Form.pdf Form and Instruction
Post Session Survey 0039 Post Session Survey.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Evidence-Based Falls Prevention Program (Project Staff)	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	Information 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
Form and Instruction	NA	Participant Information Form	0039 Participant-Information-Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Post Session Survey	0039 Post Session Survey.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: 48	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	48	8	40
Annual IC Time Burden (Hours)	469	149	320
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.