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BRFSS Optional Modules
Behavioral Risk Factor Surveillance System (BRFSS)
OMB: 0920-1061
IC ID: 214640
OMB.report
HHS/CDC
OMB 0920-1061
ICR 201604-0920-008
IC 214640
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1061 can be found here:
2024-12-04 - Revision of a currently approved collection
2023-12-11 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
BRFSS Optional Modules
Form
BRFSS Optional Modules
Attachment 4b-2015 Reference set of approved questions by optional module.docx
Form
BRFSS Sample Questionnaire
Attachment 5a-2015 BRFSS Questionnaire.docx
Form
Attachment 4a-2015 Summary of Approved Optional Modules.docx
Approved Optional Modules 2015
IC Document
Attachment 5b-Summary of Optional Modules by State.docx
Summary of Modules by State and Samples
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
BRFSS Optional Modules
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
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
none
BRFSS Optional Modules
Attachment 4b-2015 Reference set of approved questions by optional module.docx
Yes
Yes
Fillable Fileable
Form
none
BRFSS Sample Questionnaire
Attachment 5a-2015 BRFSS Questionnaire.docx
Yes
Yes
Fillable Printable
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:
484,757
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
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
484,757
0
0
0
0
484,757
Annual IC Time Burden (Hours)
121,189
0
0
0
0
121,189
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Approved Optional Modules 2015
Attachment 4a-2015 Summary of Approved Optional Modules.docx
01/14/2015
Summary of Modules by State and Samples
Attachment 5b-Summary of Optional Modules by State.docx
01/14/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.