Information Collection

Intake Information for Callers who Contact the Quitline for Someone Else

IC 193099 under ICR 201207-0920-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form E1(b) Intake Information for Callers who Contact the Quitline for Someone Else	Form and Instruction
E1(b) NQDW Intake Questionnaire Subset Final E1(b) NQDW Intake Questionnaire_Subset Final.pdf	Form and Instruction

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	E1(b)	NQDW Intake Questionnaire Subset Final	E1(b) NQDW Intake Questionnaire_Subset Final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24,688

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	24,688	-205,312	230,000
Annual IC Time Burden (Hours)	411	-3,422	3,833
Annual IC Cost Burden (Dollars)	0	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.