Information Collection

Sub-study #4_REVISED Smokefree Women Customer Satisfaction Study

IC 210671 under ICR 201304-0925-003 · OMB 0925-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0046 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Consent Sub-study #4_REVISED Smokefree Women Customer Satisfaction Study	Form and Instruction
Form 2 Screener Sub-study #4_REVISED Smokefree Women Customer Satisfaction Study	Form and Instruction
Form 3 Initial Survey Sub-study #4_REVISED Smokefree Women Customer Satisfaction Study	Form and Instruction
Form 4 Final Survey Sub-study #4_REVISED Smokefree Women Customer Satisfaction Study	Form and Instruction
1 Consent AttachA_Consent_REV_03102014.doc	Form and Instruction
2 Screener AttachC_Screener-Survey_REV_03102014.docx	Form and Instruction
3 Initial Survey AttachD_Initial-Survey_REV_03102014.docx	Form and Instruction
4 Final Survey AttachE_Customer-Satis-Survey_REV_03102014.docx	Form and Instruction
ASPE Comments_NCI-Response.docx ASPE Comments_NCI-Response	IC Document
SFW-Study_Gen-Sub-Study-Form_01172014.doc SFW-Study_Gen-Sub-Study-Form_01172014	IC Document
SFW-Study_Mini-SSB_03102014.doc SFW-Study_Mini-SSB_03102014	IC Document
AttachB_Study-Emails_03102014.doc AttachB_Study-Emails_03102014	IC Document
AttachF_OHSR_Exemption.pdf AttachF_OHSR_Exemption	IC Document
SFW-Study_Mini-SSA_03102014.doc SFW-Study_Mini-SSA_03102014	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Sub-study #4_REVISED Smokefree Women Customer Satisfaction Study

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Consent	AttachA_Consent_REV_03102014.doc	Yes	Yes	Fillable Fileable
Form and Instruction	2	Screener	AttachC_Screener-Survey_REV_03102014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Initial Survey	AttachD_Initial-Survey_REV_03102014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	Final Survey	AttachE_Customer-Satis-Survey_REV_03102014.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: 400

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 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	1,200	0	0	0	0	0
Annual IC Time Burden (Hours)	262	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ASPE Comments_NCI-Response	ASPE Comments_NCI-Response.docx	03/11/2014
SFW-Study_Gen-Sub-Study-Form_01172014	SFW-Study_Gen-Sub-Study-Form_01172014.doc	03/11/2014
SFW-Study_Mini-SSB_03102014	SFW-Study_Mini-SSB_03102014.doc	03/11/2014
AttachB_Study-Emails_03102014	AttachB_Study-Emails_03102014.doc	03/11/2014
AttachF_OHSR_Exemption	AttachF_OHSR_Exemption.pdf	03/11/2014
SFW-Study_Mini-SSA_03102014	SFW-Study_Mini-SSA_03102014.doc	03/11/2014

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