Quitline Services Questionnaire

National Quitline Data Warehouse

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0856 can be found here:

Documents and Forms

Document Name Document Type
Quitline Services Questionnaire Form
NQDW services questionnaire G1. NQDW Quitline Services Questionnaire_05-04-10.docx Form
G2. Advance Email for Services Questionnaire.docx Attachment G2 - Advance email for services questionnaire IC Document
G3. Reminder Email for Services Questionnaire.docx Attachment G3 - Reminder email for services questionnaire IC Document

Information Collection (IC) Details

IC Title:	Quitline Services Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	NQDW services questionnaire	G1. NQDW Quitline Services Questionnaire_05-04-10.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	212	212
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment G2 - Advance email for services questionnaire	G2. Advance Email for Services Questionnaire.docx	05/17/2010
Attachment G3 - Reminder email for services questionnaire	G3. Reminder Email for Services Questionnaire.docx	05/17/2010

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