Information Collection

BRFSS Optional Modules

IC 214640 under ICR 201808-0920-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 0920-1061 BRFSS Optional Modules	Form and Instruction
0920-1061 2019 Approved Questions by Optional Module Attachment 4 Approved Questions by Optional Module 12-19.docx	Form and Instruction
Attachment 4a-2017 Approved Optional Modules.docx 2017 Summary of Approved Optional Modules	IC Document

IC Title:

BRFSS Optional Modules

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	0920-1061	2019 Approved Questions by Optional Module	Attachment 4 Approved Questions by Optional Module 12-19.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 440,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	440,000	440,000
Annual IC Time Burden (Hours)	110,000	110,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2017 Summary of Approved Optional Modules	Attachment 4a-2017 Approved Optional Modules.docx	09/22/2016

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