View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	[2022] Address-based Sampling Pilot for BRFSS	Agency IC Tracking Number:	0920-1291-22IM

IC Status: New

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	None	Survey Questionnaire for ABS Pilot	Attachment 2_ ABS_Pilots_08252022.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 67 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	4,500	0	4,500	0	0	0
Annual IC Time Burden (Hours)	2,250	0	2,250	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
ABS Pilot: Project Description and Justification	Attachment 3 Data Coll Data Flow Process 082422.docx	08/25/2022
Recruitment Materials for Respondents	Attachment 1 Materials for Invitation to Participate in the ABS Project 8 24 2022.docx	08/25/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.