Information Collection

PATH/Baseline- Adults -Tobacco Use Form

IC 203759 under ICR 201307-0925-001 · OMB 0925-0664.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0664 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 PATH/Baseline- Adults -Tobacco Use Form	Form and Instruction
1 Tobacco Use Form 3e - English. PATH Wave 1 Tobacco Use Form 2013-06-10.pdf	Form and Instruction
3e. Spanish. PATH Wave 1 Tobacco Use Form 2013-06-10.pdf 3e	IC Document

IC Title:

PATH/Baseline- Adults -Tobacco Use Form

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	1	Tobacco Use Form	3e - English. PATH Wave 1 Tobacco Use Form 2013-06-10.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: NIH Privacy Act System of Records 09-25-0200 Clinical, Basic Population-based research studies of NIH, HHS/NIH/OD

FR Citation: 67 FR 60741

Number of Respondents: 42,730

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	42,730	0	42,730
Annual IC Time Burden (Hours)	2,849	1,425	1,424
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
3e	3e. Spanish. PATH Wave 1 Tobacco Use Form 2013-06-10.pdf	06/28/2013

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