Information Collection

2017 Field Test of Proposed Changes - Screener and Questionnaire

IC 226397 under ICR 201704-0920-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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
2017 Field Test of Proposed Changes - Screener and Questionnaire	Form and Instruction
18 Years) Attachment 13c- Screener for 2017 Field Test.docx	Form and Instruction
18 Years) Att 13b-2017 Field Test Questionnaire of Proposed Changes to the 2018 BRFSS 15MAY2017.docx	Form and Instruction

IC Title:

2017 Field Test of Proposed Changes - Screener and Questionnaire

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 and Instruction	NA	2017 Field Test Screener - Respondents (Adults >18 Years)	Attachment 13c- Screener for 2017 Field Test.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	2017 Field Test of Proposed Changes to the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (Adults > 18 Years)	Att 13b-2017 Field Test Questionnaire of Proposed Changes to the 2018 BRFSS 15MAY2017.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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	300	300
Annual IC Time Burden (Hours)	130	130
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.