Final Survey Phone Mode

Test Predictability of Falls Screening Tools

Documents and Forms

Document Name Document Type
Form 0920-17HO Final Survey Phone Mode Form and Instruction
0920-17HO Att B-12. Final Survey_CATI_9 26 17 Att B-12. Final Survey_CATI_9 26 17.docx Form and Instruction
Att B-3. Falls Calendar & Log.docx Att B-3. Falls Calendar & Log IC Document
Att B-4. Cover Letter for Monthly & Diary - Mail.docx Att B-4. Cover Letter for Monthly & Diary - Mail IC Document
Att B-5. Cover Letter for Monthly & Diary - Email.docx Att B-5. Cover Letter for Monthly & Diary - Email IC Document
Att B-6. Proxy Survey Protocol.docx Att B-6. Proxy Survey Protocol IC Document
Att A-11 Research Determination.pdf Att A-11 Research Determination IC Document
Att A-9. IRB Protocol.doc Att A-9. IRB Protocol IC Document

Information Collection (IC) Details

IC Title:	Final Survey Phone 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-12. Final Survey_CATI_9 26 17	Att B-12. Final Survey_CATI_9 26 17.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: 380	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	380	380
Annual IC Time Burden (Hours)	190	190
Annual IC Cost Burden (Dollars)	4,247	4,247

Documents for IC

Title	Document	Date Uploaded
Att B-3. Falls Calendar & Log	Att B-3. Falls Calendar & Log.docx	09/28/2017
Att B-4. Cover Letter for Monthly & Diary - Mail	Att B-4. Cover Letter for Monthly & Diary - Mail.docx	09/28/2017
Att B-5. Cover Letter for Monthly & Diary - Email	Att B-5. Cover Letter for Monthly & Diary - Email.docx	09/28/2017
Att B-6. Proxy Survey Protocol	Att B-6. Proxy Survey Protocol.docx	09/28/2017
Att A-11 Research Determination	Att A-11 Research Determination.pdf	09/28/2017
Att A-9. IRB Protocol	Att A-9. IRB Protocol.doc	09/28/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.