Field Test - Screener

[NCCDPHP] Behavioral Risk Factor Surveillance System (BRFSS)

Documents and Forms

Document Name Document Type
Form 0920-1061 Field Test - Screener Form and Instruction
0920-1061 BRFSS Questionnaire (Field Test) BRFSS Attachment 5 Screening Scripts and Subject Recruitment_2025-2027 Cycle.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Field Test - Screener	Agency IC Tracking Number:	0920-1061

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	BRFSS Questionnaire (Field Test)	BRFSS Attachment 5 Screening Scripts and Subject Recruitment_2025-2027 Cycle.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: 0 %

	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

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.