Information Collection

Quitline Services Questionnaire

IC 193102 under ICR 201105-0920-009 · OMB 0920-0856.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Quitline Services Questionnaire

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	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 %

table that charts list of burden
	Approved	Previously Approved
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

table that charts IC Documents
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.