BRFSS Preliminary Experiment for Sample and Mode

CDC/ATSDR Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Document Name Document Type
Attachment 4 BRFSS Core Questionnaire with Formatting.doc Other-WORD
Attachment 1 BRFSS Data Collection Protocols.docx Att 1_BRFSS Data Collection Protocols IC Document
Attachment 2 Telephone Interview Informed Consent Script.docx Att 2_Telephone Interviewer's Inform Consent IC Document
Attachment 3 Language for Informed Consent in Mailed Survey.docx Att 3_Lanaguage for Informed Consent in Mailed Survey IC Document
Attachment 5 Letter of invitation to participate in online assessment.docx Att 5_Letter of Invitation (Web based Participants) IC Document
GenICRequest_ 0920-1154(17AYR).docx Request for genIC Approval IC Document
BRFSS Sampling Preliminary Experiment Justification Part A updated.docx Sup Stmt Part A IC Document
BRFSS Sampling Preliminary Experiment Justification Part B updated.docx Sup Stmt Part B IC Document

Information Collection (IC) Details

IC Title:	BRFSS Preliminary Experiment for Sample and Mode	Agency IC Tracking Number:

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			Attachment 4 BRFSS Core Questionnaire with Formatting.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 13,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	13,500	13,500
Annual IC Time Burden (Hours)	3,375	3,375
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 1_BRFSS Data Collection Protocols	Attachment 1 BRFSS Data Collection Protocols.docx	08/16/2017
Att 2_Telephone Interviewer's Inform Consent	Attachment 2 Telephone Interview Informed Consent Script.docx	08/16/2017
Att 3_Lanaguage for Informed Consent in Mailed Survey	Attachment 3 Language for Informed Consent in Mailed Survey.docx	08/16/2017
Att 5_Letter of Invitation (Web based Participants)	Attachment 5 Letter of invitation to participate in online assessment.docx	08/16/2017
Request for genIC Approval	GenICRequest_ 0920-1154(17AYR).docx	08/16/2017
Sup Stmt Part A	BRFSS Sampling Preliminary Experiment Justification Part A updated.docx	09/11/2017
Sup Stmt Part B	BRFSS Sampling Preliminary Experiment Justification Part B updated.docx	09/11/2017

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