2017 Field Test of Proposed Changes - Screener Only

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⚠️ Notice: This information collection may be referencing outdated material.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 Only Form and Instruction
2017 Field Test Screener Only - U.S. General Population Attachment 13c- Screener for 2017 Field Test.docx Form and Instruction

Information Collection (IC) Details

IC Title:	2017 Field Test of Proposed Changes - Screener Only	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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 Only - U.S. General Population	Attachment 13c- Screener for 2017 Field Test.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: 240	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-240	240
Annual IC Time Burden (Hours)	-4	4
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.