Information Collection

2021 Field Test - Survey

IC 229653 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⚠️ Notice: This information collection may be referencing outdated material.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 2021 Field Test - Survey	Form and Instruction
0920-1061 2021 BRFFS Questionnaire 2021BRFSS Att 13 BRFSS 2021 Questionnaire.docx	Form and Instruction
0920-1061 2021 BRFFS Questionnaire 2021BRFSS Att 13 BRFSS 2021 Questionnaire.docx	Form and Instruction

IC Title:

2021 Field Test - Survey

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	2021 BRFFS Questionnaire	2021BRFSS Att 13 BRFSS 2021 Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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	500	500
Annual IC Time Burden (Hours)	13,333	13,333
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.