Information Collection

2016 Field Test of Proposed Changes to 2017 BRFSS

IC 221906 under ICR 201606-0920-009 · OMB 0920-1061.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1061 can be found here:

Documents and Forms

Document Name Document Type
Att 13b-Field Test Questionnaire_06242016.docx Other-WORD
Attachment 13c- Screener for Field Test.docx Other-WORD
Att 13d-Source of questions on the 2016 BRFSS Field Test_06242016.docx Att. 13d_Source of Question on 2016 BRFSS Field Test IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2016 Field Test of Proposed Changes to 2017 BRFSS	Agency IC Tracking Number:

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
Other-WORD			Att 13b-Field Test Questionnaire_06242016.docx		Yes	Yes	Fillable Fileable
Other-WORD			Attachment 13c- Screener for Field Test.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 540	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	540	540
Annual IC Time Burden (Hours)	135	135
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att. 13d_Source of Question on 2016 BRFSS Field Test	Att 13d-Source of questions on the 2016 BRFSS Field Test_06242016.docx	06/27/2016

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