Information Collection

Individuals

IC 211374 under ICR 201404-0925-002 · OMB 0925-0368.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1-Rev Individuals	Form and Instruction
1 Main 2014-2015 Tobacco Use Supplement Questionnaire A1_TUS-CPS Questionnaire_2014-15_4-3-14.doc	Form
1-Rev Revised 2014-2015 TUS-CPS Form A1_TUS-CPS Questionnaire_2014-15 (3).docx	Form and Instruction
A14_TUS-CPS Qx Spanish DRAFT_2014-2015.docx 2014-2015 DRAFT Spanish Version TUS-CPS	IC Document
Final 2014 Spanish Short Form 24Jun2014 (3).docx 2014-2015 REVISED Spanish TUS_CPS Version	IC Document

IC Title:

Individuals

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 and Instruction	1-Rev	Revised 2014-2015 TUS-CPS Form	A1_TUS-CPS Questionnaire_2014-15 (3).docx		Yes	Yes	Fillable Fileable
Form	1	Main 2014-2015 Tobacco Use Supplement Questionnaire	A1_TUS-CPS Questionnaire_2014-15_4-3-14.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 127,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	127,500	127,500
Annual IC Time Burden (Hours)	12,750	12,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2014-2015 DRAFT Spanish Version TUS-CPS	A14_TUS-CPS Qx Spanish DRAFT_2014-2015.docx	04/28/2014
2014-2015 REVISED Spanish TUS_CPS Version	Final 2014 Spanish Short Form 24Jun2014 (3).docx	06/24/2014

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