Information Collection

DBS Gulf Coast Survey - BRFSS Stand Alone

IC 194809 under ICR 201010-0920-003 · OMB 0920-0868.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form no number DBS Gulf Coast Survey - BRFSS Stand Alone	Form
no number BRFSS Stand Alone BRFSS stand alone questionnaire clean version 10-04-2010.doc	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	no number	BRFSS Stand Alone	BRFSS stand alone questionnaire clean version 10-04-2010.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	15,000	15,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.