Information Collection

Quitline Services Questionnaire

IC 193102 under ICR 201401-0920-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 G1 Quitline Services Questionnaire	Form and Instruction
G1 Quitline Serivces Online Survey G1 Quitline Services Online Survey_file 1.pdf	Form and Instruction
G1 (2) G1 Quitline Services Online Survey file 2 G1 Quitline Services Online Survey_file 2.pdf	Form and Instruction
G3 Quitline Services Survey G3. NQDW Quitline Services Survey_Dec 2013.docx	Form
G2. Advance Email for Services Questionnaire.docx G2	IC Document
G3. Reminder Email for Services Questionnaire.docx G3	IC Document

IC Title:

Quitline Services Questionnaire

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	G1	Quitline Serivces Online Survey	G1 Quitline Services Online Survey_file 1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	G1 (2)	G1 Quitline Services Online Survey file 2	G1 Quitline Services Online Survey_file 2.pdf	Yes	Yes	Fillable Fileable
Form	none	G3 Quitline Services Survey	G3. NQDW Quitline Services Survey_Dec 2013.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 53

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	212	212
Annual IC Time Burden (Hours)	71	71
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
G2	G2. Advance Email for Services Questionnaire.docx	09/19/2012
G3	G3. Reminder Email for Services Questionnaire.docx	09/19/2012

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