Information Collection

Smoker Follow-up Survey Wave 5

IC 210360 under ICR 201411-0920-011 · OMB 0920-0923.

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Smoker Follow-up Survey Wave 5	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	none	Smoker follow-up survey waves 2-5 Spanish	Smoker Follow-Up Surveys (Waves 2-5) (REVISED SPANISH Screenshots).pdf		Yes	Yes	Fillable Fileable
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

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 %

	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

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.