Information Collection

BRFSS Core Survey

IC 214638 under ICR 201704-0920-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Attachment 5a-2017 BRFSS Core Survey	Form and Instruction
Attachment 5a-2017 2017 BRFSS Core Survey Questionnaire Attachment 5a-2017 BRFSS questionnaire.docx	Form and Instruction

IC Title:

BRFSS Core Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	Attachment 5a-2017	2017 BRFSS Core Survey Questionnaire	Attachment 5a-2017 BRFSS 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: 494,650

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	494,650	494,650
Annual IC Time Burden (Hours)	123,663	123,663
Annual IC Cost Burden (Dollars)	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.