Participant Information Forms

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

Documents and Forms

Document Name Document Type
Participant Information Forms Form and Instruction
Participant Information Form 0039 Participant-Information-Form.pdf Form and Instruction
Participant Post Session Survey 0039 Post Session Survey.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Participant Information Forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	NA	Participant Information Form	0039 Participant-Information-Form.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	NA	Participant 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: 19,624	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	19,624	2,896	16,728
Annual IC Time Burden (Hours)	1,961	287	1,674
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.