2017 Field Test of Proposed Changes - Screener and Questionnaire

Behavioral Risk Factor Surveillance System (BRFSS)

⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 %

	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

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.