Information Collection

12 Week Post Quit Date Questionnaire (Attachment 19)

IC 206358 under ICR 201304-0925-001 · OMB 0925-0676.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 12 Week Post Quit Date Questionnaire (Attachment 19)	Form and Instruction
5 12 Week Post Quit Date Questionnaire Attach19_SFTXT_12WeekSurvey_12062012.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

12 Week Post Quit Date Questionnaire (Attachment 19)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	5	12 Week Post Quit Date Questionnaire	Attach19_SFTXT_12WeekSurvey_12062012.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: SORN #09-25-0156, "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: 1,088

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
Annual Number of Responses for this IC	1,088	1,088
Annual IC Time Burden (Hours)	272	272
Annual IC Cost Burden (Dollars)	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.