2022 Field Test Questionnaire

[NCCDPHP] 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-1061 2022 Field Test Questionnaire Form and Instruction
0920-1061 2022 Field Test Questionnaire 2022 Field Test for 2023 BRFSS Questionnaire_20220830_clean.docx Form and Instruction
0920-1061 2022 Field Test Questionnaire 2022 Field Test for 2023 BRFSS Questionnaire_20220830_clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	2022 Field Test Questionnaire	Agency IC Tracking Number:	0920-1061-24BN

Is this a Common Form? No		IC Status: Modified

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	0920-1061	2022 Field Test Questionnaire	2022 Field Test for 2023 BRFSS Questionnaire_20220830_clean.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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	200	300
Annual IC Time Burden (Hours)	375	275	100
Annual IC Cost Burden (Dollars)	0	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.