Smoker Wave 1 Survey

Evaluation of the National Tobacco Prevention and Control Public Education Campaign

Documents and Forms

Document Name Document Type
Smoker Wave 1 Survey Form and Instruction
Smoker Wave 1 Questionnaire - screenshots Attachment C-2 (Screenshots) 2-6-14.pdf Form and Instruction
Smoker Wave 1 Questionnaire - Spanish screenshots Attachment C-2 (Screenshots Spanish) 2-6-14.pdf Form
Attachment C-2 (Spanish) 2-6-14.docx Smoker Wave 1 Questionnaire - Spanish word IC Document
Attachment C-2 Smoker Wave 1 Survey_2-6-14.docx Smoker Wave 1 Questionnaire - word IC Document

Information Collection (IC) Details

IC Title:	Smoker Wave 1 Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Smoker Wave 1 Questionnaire - screenshots	Attachment C-2 (Screenshots) 2-6-14.pdf		Yes	Yes	Fillable Fileable
Form	none	Smoker Wave 1 Questionnaire - Spanish screenshots	Attachment C-2 (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: 4,720	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	4,720	4,720
Annual IC Time Burden (Hours)	2,360	2,360
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Smoker Wave 1 Questionnaire - Spanish word	Attachment C-2 (Spanish) 2-6-14.docx	02/10/2014
Smoker Wave 1 Questionnaire - word	Attachment C-2 Smoker Wave 1 Survey_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.