2021 Field Test - Survey

2021 Field Test 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⚠️ Notice: This information collection may be referencing outdated material.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 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

Information Collection (IC) Details

IC Title:	2021 Field Test - Survey	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	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	0	500
Annual IC Time Burden (Hours)	13,333	12,958	375
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.