National Quitline Data Warehouse

Forms and Documents

Document Name	Status
Form G1 Quitline Services Questionnaire Form and Instruction	Modified
Form F1 Follow-up for Callers who Received a Quitline Service Form and Instruction	Modified
Form E1(a) Intake Information for Callers who Contact the Quitline for Personal Use Form and Instruction	Modified
Form E1(b) Intake Information for Callers who Contact the Quitline for Someone Else Form and Instruction	Modified
0920-0856 Change Request 1_6_14.docx Justification for No Material/Nonsubstantive Change	2014-01-08
G3. Reminder Email for Services Questionnaire.docx Supplementary Document	2012-09-19
G2. Advance Email for Services Questionnaire.docx Supplementary Document	2012-09-19
F2. NQDW Advance Letter for Folllow-up.doc Supplementary Document	2012-09-19

IC Document Collections

IC ID	Document Title	Status
204102	Instructions for submitting caller intake and follow up Instruction	Modified
193102	Quitline Services Questionnaire Form and Instruction	Modified
193101	Follow-up for Callers who Received a Quitline Service Form and Instruction	Modified
193100	Intake Information for Callers who Contact the Quitline for Personal Use Form and Instruction	Modified
193099	Intake Information for Callers who Contact the Quitline for Someone Else Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0856	ICR Reference No: 201401-0920-003
Status: Historical Active	Previous ICR Reference No: 201305-0920-014
Agency/Subagency: HHS/CDC	Agency Tracking No: 21302
Title: National Quitline Data Warehouse
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/13/2014
	Date Received in OIRA: 01/09/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2015	10/31/2015	10/31/2015
Responses	564,621	0	564,621
Time Burden (Hours)	89,035	0	89,035
Cost Burden (Dollars)	0	0	0

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Abstract: The NQDW Quitline Services Survey has been redesigned to reflect the design and display of the NQDW data in State Tobacco Activities and Evaluation System. Clarified instructions are provided.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
   PL: Pub.L. 111 - 148 4002 Name of Law: Patient Protection and Affordable Care Act PPHF
   PL: Pub.L. 111 - 5 1 Name of Law: American Recovery and Reinvestment Act of 2009
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Intake Information for Callers who Contact the Quitline for Someone Else	E1(b)	NQDW Intake Questionnaire Subset Final
Intake Information for Callers who Contact the Quitline for Personal Use	E1(a)	NQDW Intake Questionnaire
Follow-up for Callers who Received a Quitline Service	F1	NQDW 7-Month Follow-Up Questionnaire
Quitline Services Questionnaire	G1, G1 (2), none	Quitline Serivces Online Survey ,   G1 Quitline Services Online Survey file 2 ,   G3 Quitline Services Survey
Instructions for submitting caller intake and follow up

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	564,621	564,621	0	0	0	0
Annual Time Burden (Hours)	89,035	89,035	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,085,301

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/09/2014

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