Information Collection

Smoker Follow-up Survey Wave 5

IC 210360 under ICR 201408-0920-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 - Screenshots Smoker Follow-up Survey Wave 5	Form
Smoker Follow-up Survey Wave 5 - Spanish screenshots 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: Unchanged

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
	Requested	Previously Approved
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.