BRFSS Optional Modules

2021 Field Test 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-1061 BRFSS Optional Modules Form and Instruction
0920-1061 Attachment 4 Optional Modules by Topic 6-30 Attachment 4 Optional Modules by Topic 6-30.docx Form and Instruction
0920-1061 Attachment 4 Optional Modules by Topic 6-30 Attachment 4 Optional Modules by Topic 6-30.docx Form and Instruction
Attachment 4a-2017 Approved Optional Modules.docx 2017 Summary of Approved Optional Modules IC Document
Attachment 4a-2017 Approved Optional Modules.docx 2017 Summary of Approved Optional Modules IC Document

Information Collection (IC) Details

IC Title:	BRFSS Optional Modules	Agency IC Tracking Number:	0920-1061

Is this a Common Form? No		IC Status: Modified

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	0920-1061	Attachment 4 Optional Modules by Topic 6-30	Attachment 4 Optional Modules by Topic 6-30.docx		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: 0 %

	Approved	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

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.