Information Collection

Non-Smoker Baseline Questionnaire

IC 200740 under ICR 201201-0920-004 · OMB 0920-0923.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0923 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Non-Smoker Baseline Questionnaire	Form
NonSmoker Baseline Att D-1 Nonsmoker Baseline Survey_1-6-12.docx	Form

IC Title:

Non-Smoker Baseline 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	none	NonSmoker Baseline	Att D-1 Nonsmoker Baseline Survey_1-6-12.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,666

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,666	2,666
Annual IC Time Burden (Hours)	1,111	1,111
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.