Intake Information for Callers who Contact the Quitline for Personal Use

National Quitline Data Warehouse

⚠️ Notice: This information collection may be referencing outdated material.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
Form E1(a) Intake Information for Callers who Contact the Quitline for Personal Use Form and Instruction
E1(a) NQDW Intake Questionnaire E1(a) NQDW Intake Questionnaire_complete final.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Intake Information for Callers who Contact the Quitline for Personal Use	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 and Instruction	E1(a)	NQDW Intake Questionnaire	E1(a) NQDW Intake Questionnaire_complete final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 510,768	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	510,768	10,768	500,000
Annual IC Time Burden (Hours)	85,128	1,795	83,333
Annual IC Cost Burden (Dollars)	0	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.