Evidence-Based Falls Prevention Program (Local Respondents)

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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Evidence-Based Falls Prevention Program (Local Respondents)	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	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 %

	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

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.