Monthly Update Survey (Months 1-11) Web Mode

Test Predictability of Falls Screening Tools

Documents and Forms

Document Name Document Type
Form 0920-17HO Monthly Update Survey (Months 1-11) Web Mode Form and Instruction
0920-17HO Att B-9. Falls Monthly Survey Screenshots Att B-9. Falls Monthly Survey Screenshots.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Monthly Update Survey (Months 1-11) Web Mode	Agency IC Tracking Number:	0920-17HO

Is this a Common Form? No		IC Status: New

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	0920-17HO	Att B-9. Falls Monthly Survey Screenshots	Att B-9. Falls Monthly Survey Screenshots.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 252

Number of Respondents: 570	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,270	6,270
Annual IC Time Burden (Hours)	1,045	1,045
Annual IC Cost Burden (Dollars)	23,356	23,356

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.