Information Collection

Field Test Questionnaire

IC 229653 under ICR 202411-0920-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Questionnaire	Form and Instruction
0920-1061 2022 Field Test Questionnaire BRFSS Attachment 12 Field Test for BRFSS Questionnaire_2025-2027.docx	Form and Instruction

IC Title:

Field Test Questionnaire

Agency IC Tracking Number:

0920-1061

Is this a Common Form? No

IC Status: Modified

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	2022 Field Test Questionnaire	BRFSS Attachment 12 Field Test for BRFSS Questionnaire_2025-2027.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: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	0	500
Annual IC Time Burden (Hours)	167	-208	375
Annual IC Cost Burden (Dollars)	0	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.