Information Collection

PATH/Baseline- Adults -Tobacco Use Form

IC 203759 under ICR 201208-0925-002 · OMB 0925-0664.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0664 can be found here:

Documents and Forms

Document Name Document Type
Form 2e PATH/Baseline- Adults -Tobacco Use Form Form
2e Tobacco Use Form/Baseline 2e. Tobacco Use Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PATH/Baseline- Adults -Tobacco Use Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	2e	Tobacco Use Form/Baseline	2e. Tobacco Use Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: NIH Privacy Act System of Records 09-25-0200 Clinical, Basic Population-based research studies of NIH, HHS/NIH/OD	FR Citation: 67 FR 60741

Number of Respondents: 42,730	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42,730	42,730
Annual IC Time Burden (Hours)	1,424	1,424
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.