Information Collection

CIS Smoking Cessation Proactive Follow-up (Appendix 1D)

IC 189806 under ICR 201208-0925-003 · OMB 0925-0208.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0208 can be found here:

Documents and Forms

Document Name Document Type
Form 6 CIS Smoking Cessation Proactive Follow-up (Appendix 1D) Form and Instruction
6 Smoking Cessation Proactive Follow-Up Appendix 1D Proactive Smoking Cessation Questions.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CIS Smoking Cessation Proactive Follow-up (Appendix 1D)	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	6	Smoking Cessation Proactive Follow-Up	Appendix 1D Proactive Smoking Cessation Questions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD	FR Citation: 67 FR 60743

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,000	288	3,712
Annual IC Time Burden (Hours)	67	5	62
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.