Information Collection

Field Test - Screener

IC 229652 under ICR 202205-0920-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-1061 Field Test - Screener	Form and Instruction
0920-1061 Field Test Screener 2021BRFSS Att 12 BRFSS Field test Questionnaire Example 4-26.docx	Form and Instruction
0920-1061 Field Test Screener 2021BRFSS Att 12 BRFSS Field test Questionnaire Example 4-26.docx	Form and Instruction

IC Title:

Field Test - Screener

Agency IC Tracking Number:

0920-1061

Is this a Common Form? No

IC Status: Unchanged

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	0920-1061	Field Test Screener	2021BRFSS Att 12 BRFSS Field test Questionnaire Example 4-26.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	15	15
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.