Information Collection

Non-Smoker Survey Wave 1

IC 200741 under ICR 201411-0920-011 · OMB 0920-0923.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Non-Smoker Survey Wave 1	Form
Non-smoker Survey Wave 1 - Spanish screenshots Attachment C-4 (Screenshots Spanish) 2-6-14.pdf	Form
Non-smoker Survey Wave 1 screenshots Attachment C-4 (Screenshots) 2-6-14.pdf	Form
Attachment C-4 (Spanish) 2-6-14.docx Non-Smoker Survey Wave 1 - Spanish	IC Document
Attachment C-4 Nonsmoker Wave 1 Survey 2-6-14.docx Non-Smoker Survey Wave 1 - word	IC Document

IC Title:

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	Non-smoker Survey Wave 1 - Spanish screenshots	Attachment C-4 (Screenshots Spanish) 2-6-14.pdf		Yes	Yes	Fillable Fileable
Form	none	Non-smoker Survey Wave 1 screenshots	Attachment C-4 (Screenshots) 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: 1,400

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	Previously Approved
Annual Number of Responses for this IC	1,400	1,400
Annual IC Time Burden (Hours)	700	700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Non-Smoker Survey Wave 1 - Spanish	Attachment C-4 (Spanish) 2-6-14.docx	02/10/2014
Non-Smoker Survey Wave 1 - word	Attachment C-4 Nonsmoker 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.