BRFSS Optional Modules

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⚠️ Notice: This information collection may be referencing outdated material.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

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

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	Previously Approved
Annual Number of Responses for this IC	484,757	484,757
Annual IC Time Burden (Hours)	121,189	121,189
Annual IC Cost Burden (Dollars)	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.