Information Collection

National Adult Tobacco Survey Questionnaire

IC 190630 under ICR 200909-0920-003 · OMB 0920-0828.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0828 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
National Adult Tobacco Survey Questionnaire	Form and Instruction
Appendix F (English language) Appendix F (English language) 10 06 09.doc	Form and Instruction
Appendix G (Spanish Language) Appendix G (Spanish Language) 10 06 09.doc	Form and Instruction

IC Title:

National Adult Tobacco Survey Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	N/A	Appendix F (English language)	Appendix F (English language) 10 06 09.doc		Yes	No	Fillable Printable
Form and Instruction	N/A	Appendix G (Spanish Language)	Appendix G (Spanish Language) 10 06 09.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 98,013

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	98,013	98,013
Annual IC Time Burden (Hours)	32,671	32,671
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.