Information Collection

Intake Information for Callers who Contact the Quitline for Personal Use

IC 193100 under ICR 201305-0920-014 · OMB 0920-0856.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form E1(a) Intake Information for Callers who Contact the Quitline for Personal Use	Form and Instruction
E1(a) NQDW Intake Questionnaire E1(a) NQDW Intake Questionnaire_complete final.pdf	Form and Instruction

IC Title:

Intake Information for Callers who Contact the Quitline for Personal Use

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	E1(a)	NQDW Intake Questionnaire	E1(a) NQDW Intake Questionnaire_complete final.pdf		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 510,768

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	Previously Approved
Annual Number of Responses for this IC	510,768	510,768
Annual IC Time Burden (Hours)	85,128	85,128
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.