Information Collection

Smoker Follow-up Survey Wave 3

IC 210358 under ICR 201411-0920-011 · OMB 0920-0923.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Smoker Follow-up Survey Wave 3	Form
Smoker follow-up survey waves 2-5 Spanish Smoker Follow-Up Surveys (Waves 2-5) (REVISED SPANISH Screenshots).pdf	Form
Smoker follow-up survey waves 2-5 Attachment C-3. Smoker Follow-Up Survey (Waves 2-5) (REVISED SCREENSHOTS).pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 waves 2-5	Attachment C-3. Smoker Follow-Up Survey (Waves 2-5) (REVISED SCREENSHOTS).pdf		Yes	Yes	Fillable Fileable
Form	none	Smoker follow-up survey waves 2-5 Spanish	Smoker Follow-Up Surveys (Waves 2-5) (REVISED SPANISH Screenshots).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	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
No associated records found

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