Information Collection

2013 Smoker Follow-up Questionnaire (Phase 2)

IC 200739 under ICR 201302-0920-014 · OMB 0920-0923.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0923 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0923 2013 Smoker Follow-up Questionnaire (Phase 2)	Form and Instruction
0920-0923 Att I-b. 2012 SmokerFollow-UpSurvey(C-2) Att I-b. 2012 SmokerFollow-UpSurvey(C-2).pdf	Form and Instruction
Att C-2b. Smoker Survey_Screenshots Rev Dec28 v2.pdf Att C-2b. Smoker Survey_Screenshots Rev Dec28 v2	IC Document
Att I-a. 2012 Smoker_Baseline_Questionnaire (C-1).docx Att I-a. 2012 Smoker_Baseline_Questionnaire (C-1)	IC Document

IC Title:

2013 Smoker Follow-up Questionnaire (Phase 2)

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	0920-0923	Att I-b. 2012 SmokerFollow-UpSurvey(C-2)	Att I-b. 2012 SmokerFollow-UpSurvey(C-2).pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,250

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	14,250	9,250	5,000
Annual IC Time Burden (Hours)	5,938	3,855	2,083
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att C-2b. Smoker Survey_Screenshots Rev Dec28 v2	Att C-2b. Smoker Survey_Screenshots Rev Dec28 v2.pdf	02/07/2013
Att I-a. 2012 Smoker_Baseline_Questionnaire (C-1)	Att I-a. 2012 Smoker_Baseline_Questionnaire (C-1).docx	02/13/2013

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