Intake Information for Callers who Contact the Quitline for Someone Else

National Quitline Data Warehouse

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0856 can be found here:

Documents and Forms

Document Name Document Type
Form E1(b) Intake Information for Callers who Contact the Quitline for Someone Else Form and Instruction
E1(b) NQDW Intake Questionnaire Subset Final E1(b) NQDW Intake Questionnaire_Subset Final.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Intake Information for Callers who Contact the Quitline for Someone Else	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	E1(b)	NQDW Intake Questionnaire Subset Final	E1(b) NQDW Intake Questionnaire_Subset Final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24,688	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	24,688	24,688
Annual IC Time Burden (Hours)	411	411
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.