National Quitline Data Warehouse

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
NQDW services questionnaire	Form	Modified	Available
NQDW 7month follow up questionnaire	Form	Modified	Available
NQDW intake questionnaire	Form	Modified	Available
Form #1 Revised National Quitline Data Warehouse Intake Questionnaire	Form	Modified	Available
NQDW intake questionnaire	Form	Modified	Available
G1 NQDW Services Survey_3_20_2012 (2).pdf	Supplementary Document	Uploaded 2012-03-28	Available
0920-0856 Change Request 3_Justification_3 20 2012 (2).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2012-03-28	Available
G3. Reminder Email for Services Questionnaire.docx	Supplementary Document	Uploaded 2010-05-17	Available
G2. Advance Email for Services Questionnaire.docx	Supplementary Document	Uploaded 2010-05-17	Available
F2. NQDW Advance Letter for Folllow-up.doc	Supplementary Document	Uploaded 2010-05-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
193102	Quitline Services Questionnaire	Form	Modified	NQDW services questionnaire
193101	Follow-up for Callers who Received a Quitline Service	Form	Modified	NQDW 7month follow up questionnaire
193100	Intake Information for Callers who Contact the Quitline for Personal Use	Form	Modified	NQDW intake questionnaire
193099	Intake Information for Callers who Contact the Quitline for Someone Else	Form	Modified	National Quitline Data Warehouse Intake Questionnaire
193099	Intake Information for Callers who Contact the Quitline for Someone Else	Form	Modified	NQDW intake questionnaire

ICR Details

OMB Control No: 0920-0856	ICR Reference No: 201203-0920-010
Status: Historical Active	Previous ICR Reference No: 201203-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Quitline Data Warehouse
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/28/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/28/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2012	07/31/2012	07/31/2012
Responses	759,112	0	759,112
Time Burden (Hours)	90,563	0	90,563
Cost Burden (Dollars)	0	0	0

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Abstract: CDC will collect newly standardized information from Quitline service providers in 50 states, DC, Puerto Rico and Guam. Data about each program will be collected, as well as caller intake and follow-up data. Information will be used for program improvement and to evaluate the expenditure of funding provided by the ARRA of 2009.

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Authorizing Statute(s): PL: Pub.L. 111 - 5 1 Name of Law: American Recovery and Reinvestment Act of 2009
   US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Follow-up for Callers who Received a Quitline Service	none	NQDW 7month follow up questionnaire
Intake Information for Callers who Contact the Quitline for Personal Use	none	NQDW intake questionnaire
Intake Information for Callers who Contact the Quitline for Someone Else	none, #1 Revised	NQDW intake questionnaire ,   National Quitline Data Warehouse Intake Questionnaire
Quitline Services Questionnaire	none	NQDW services questionnaire

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	759,112	759,112	0	0	0	0
Annual Time Burden (Hours)	90,563	90,563	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $3,125,962

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/28/2012

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