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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.