Information Collection

Stay Independent Fall Risk Screener

IC 238162 under ICR 202004-0920-007 · OMB 0920-1281.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1281 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-19ARD Stay Independent Fall Risk Screener Form and Instruction
0920-19ARD Fall Risk Screener Att D _Stay Independent Fall Risk Screener.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Stay Independent Fall Risk Screener	Agency IC Tracking Number:	0920-19ARD

Is this a Common Form? No		IC Status: Removed

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	0920-19ARD	Fall Risk Screener	Att D _Stay Independent Fall Risk Screener.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,035	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-4,035	4,035
Annual IC Time Burden (Hours)	-404	404
Annual IC Cost Burden (Dollars)	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.