Information Collection

Intake Information for Callers who Contact the Quitline for Someone Else

IC 193099 under ICR 201203-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Intake Information for Callers who Contact the Quitline for Someone Else Form
NQDW intake questionnaire E1. NQDW Intake Questionnaire_05-04-10.docx Form
#1 Revised National Quitline Data Warehouse Intake Questionnaire E1. NQDW Intake Questionnaire_Revised 2 23 2012.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Intake Information for Callers who Contact the Quitline for Someone Else	Agency IC Tracking Number:

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	none	NQDW intake questionnaire	E1. NQDW Intake Questionnaire_05-04-10.docx		Yes	Yes	Fillable Fileable
Form	#1 Revised	National Quitline Data Warehouse Intake Questionnaire	E1. NQDW Intake Questionnaire_Revised 2 23 2012.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 230,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	230,000	230,000
Annual IC Time Burden (Hours)	3,833	3,833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.