OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

12 Week Post Quit Date Questionnaire (Attachment 19)

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

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

12 Week Post Quit Date Questionnaire (Attachment 19)
 
No New
 
Voluntary
 

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

Health Consumer Health and Safety

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"   67 FR 60743

1,088 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,088 0 1,088 0 0 0
Annual IC Time Burden (Hours) 272 0 272 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.