Information Collection

Smoker Follow-up Survey Wave 5

IC 210360 under ICR 201402-0920-011 · OMB 0920-0923.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0923 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Smoker Follow-up Survey Wave 5	Form
Smoker Follow-up Survey Wave 5 - Screenshots Attachment C-3 (Screenshots) 2-6-14.pdf	Form
Smoker Follow-up Survey Wave 5 - Spanish screenshots Attachment C-3 (Screenshots Spanish) 2-6-14.pdf	Form
Attachment C-3 Smoker Follow-Up Survey (Waves 2-5)_2-6-14.docx Smoker Follow-up Survey Wave 5 - word	IC Document
Attachment C-3 (Spanish) 2-6-14.docx Smoker Follow-up Survey Wave 5 - Spanish	IC Document

IC Title:

Smoker Follow-up Survey Wave 5

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	none	Smoker Follow-up Survey Wave 5 - Screenshots	Attachment C-3 (Screenshots) 2-6-14.pdf		Yes	Yes	Fillable Fileable
Form	none	Smoker Follow-up Survey Wave 5 - Spanish screenshots	Attachment C-3 (Screenshots Spanish) 2-6-14.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,982

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,982	1,982
Annual IC Time Burden (Hours)	991	991
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Smoker Follow-up Survey Wave 5 - word	Attachment C-3 Smoker Follow-Up Survey (Waves 2-5)_2-6-14.docx	02/10/2014
Smoker Follow-up Survey Wave 5 - Spanish	Attachment C-3 (Spanish) 2-6-14.docx	02/10/2014

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