National Quitline Data Warehouse

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
ASQ Intake Questionnaire (Vietnamese - Subset)	Form and Instruction	New	Available
ASQ Intake Questionnaire (Korean - Subset)	Form and Instruction	New	Available
ASQ Intake Questionnaire (Chinese - Subset)	Form and Instruction	New	Available
NQDW 7-Month Follow-Up Questionnaire - Vietnamese	Form and Instruction	New	Available
NQDW 7-Month Follow-Up Questionnaire - Korean	Form and Instruction	New	Available
NQDW 7-Month Follow-Up Questionnaire - Chinese	Form and Instruction	New	Available
NQDW 7-Month Follow-Up Questionnaire - English	Form and Instruction	New	Available
NQDW Intake Questionnaire - Vietnamese Complete	Form and Instruction	New	Available
NQDW Intake Questionnaire - Korean Complete	Form and Instruction	New	Available
NQDW Intake Questionnaire - Chinese Complete	Form and Instruction	New	Available
National Quitline Data Warehouse (NQDW) Quitline Services Survey	Form and Instruction	Modified	Available
Form F1 NQDW 7-Month Follow-Up Questionnaire	Form and Instruction	Removed	Available
NQDW Intake Questionnaire - Complete	Form and Instruction	Modified	Available
NQDW Intake Questionnaire - Subset	Form and Instruction	Modified	Available
CDC Quitline SS Part A_rev 03 21 2016_OMB_FINAL.docx	Supporting Statement A	Uploaded 2016-03-23	Available
H-6 Reminder Email NQDW Quitline Services Survey.docx	Supplementary Document	Uploaded 2015-10-09	Available
H-5 Request Email NQDW Quitline Services Survey.docx	Supplementary Document	Uploaded 2015-10-09	Available
H-4 Reminder Email_Non-respondents_NQDW_ASQ 7_mo follow up.docx	Supplementary Document	Uploaded 2015-10-09	Repair queued
H-3 Request Email to submit NQDW_ASQ 7_mo follow up.docx	Supplementary Document	Uploaded 2015-10-09	Repair queued
H-2 Reminder Email for Non-respondents for intake data submsision.docx	Supplementary Document	Uploaded 2015-10-09	Available
H-1 Request Email to submit NQDW Intake Questionnaire data.docx	Supplementary Document	Uploaded 2015-10-09	Available
I. Sample Table Shells.pdf	Supplementary Document	Uploaded 2015-10-09	Available
NQDW_research detrmination.pdf	Supplementary Document	Uploaded 2015-10-09	Available
C. Consultants on NQDW.docx	Supplementary Document	Uploaded 2015-10-09	Available
B Federal Register Notice.pdf	Supplementary Document	Uploaded 2015-10-09	Available
A-2 ARRA of 2009.pdf	Supplementary Document	Uploaded 2015-10-09	Available
A-3 ACA Section 4002 PPHF.pdf	Supplementary Document	Uploaded 2015-10-09	Available
A-1 PHSA.doc	Supplementary Document	Uploaded 2015-10-09	Repair queued
CDC Quitline SS Part B_rev 03 18 2016_OMB_R1.docx	Supporting Statement B	Uploaded 2016-03-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
218546	Submission of NQDW ASQ Seven-Month Follow-Up Electronic Data File to CDC	Instruction	New
218545	ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	Form and Instruction	New	ASQ Intake Questionnaire (Vietnamese - Subset)
218545	ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	Form and Instruction	New	ASQ Intake Questionnaire (Korean - Subset)
218545	ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	Form and Instruction	New	ASQ Intake Questionnaire (Chinese - Subset)
218544	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	Form and Instruction	New	NQDW 7-Month Follow-Up Questionnaire - Vietnamese
218544	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	Form and Instruction	New	NQDW 7-Month Follow-Up Questionnaire - Korean
218544	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	Form and Instruction	New	NQDW 7-Month Follow-Up Questionnaire - Chinese
218544	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	Form and Instruction	New	NQDW 7-Month Follow-Up Questionnaire - English
218543	Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	Form and Instruction	New	NQDW Intake Questionnaire - Vietnamese Complete
218543	Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	Form and Instruction	New	NQDW Intake Questionnaire - Korean Complete
218543	Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	Form and Instruction	New	NQDW Intake Questionnaire - Chinese Complete
204102	Submission of NQDW Intake Questionnaire Electronic Data File to CDC	Instruction	Modified
193102	NQDW Quitline Services Survey	Form and Instruction	Modified	National Quitline Data Warehouse (NQDW) Quitline Services Survey
193101	Follow-up for Callers who Received a Quitline Service	Form and Instruction	Removed	NQDW 7-Month Follow-Up Questionnaire
193100	NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves	Form and Instruction	Modified	NQDW Intake Questionnaire - Complete
193099	NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else	Form and Instruction	Modified	NQDW Intake Questionnaire - Subset

ICR Details

OMB Control No: 0920-0856	ICR Reference No: 201509-0920-013
Status: Historical Active	Previous ICR Reference No: 201502-0920-013
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0856
Title: National Quitline Data Warehouse
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/24/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/14/2015
Terms of Clearance: Approved consistent with the understanding that data from tobacco users as gathered by this collection is limited to only those tobacco users who receive services from funded state telephone quitlines. Information gathered are thus not representative of, or generalizable to, the general US population of tobacco users, but only those who contact their state quitlines regarding cessation support services.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved	03/31/2016
Responses	506,656	0	564,621
Time Burden (Hours)	80,709	0	89,035
Cost Burden (Dollars)	0	0	0

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Abstract: CDC is requesting approval for Revisions to the National Quitline Data Warehouse (NQDW) Quitline Services Survey.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 4002 Name of Law: Patient Protection and Affordable Care Act PPHF
   US Code: 42 USC 241 Name of Law: Public Health Service Act
   PL: Pub.L. 111 - 5 1 Name of Law: American Recovery and Reinvestment Act of 2009
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 32383	06/08/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 61211	10/09/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	NA, NA, NA	ASQ Intake Questionnaire (Chinese - Subset) ,   ASQ Intake Questionnaire (Korean - Subset) ,   ASQ Intake Questionnaire (Vietnamese - Subset)
Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	NA, NA, NA	NQDW Intake Questionnaire - Chinese Complete ,   NQDW Intake Questionnaire - Korean Complete ,   NQDW Intake Questionnaire - Vietnamese Complete
Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	NA, NA, NA, NA	NQDW 7-Month Follow-Up Questionnaire - English ,   NQDW 7-Month Follow-Up Questionnaire - Chinese ,   NQDW 7-Month Follow-Up Questionnaire - Korean ,   NQDW 7-Month Follow-Up Questionnaire - Vietnamese
Follow-up for Callers who Received a Quitline Service	F1	NQDW 7-Month Follow-Up Questionnaire
NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves	NA	NQDW Intake Questionnaire - Complete
NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else	NA	NQDW Intake Questionnaire - Subset
NQDW Quitline Services Survey	NA	National Quitline Data Warehouse (NQDW) Quitline Services Survey
Submission of NQDW ASQ Seven-Month Follow-Up Electronic Data File to CDC
Submission of NQDW Intake Questionnaire Electronic Data File to CDC

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	506,656	564,621	0	-57,965	0	0
Annual Time Burden (Hours)	80,709	89,035	0	-8,326	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Modification in Burden Hours are the result of revisions made to the NQDW Questionnaire and addition of Questionnaire in additional languages.

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Annual Cost to Federal Government: $1,257,220

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/14/2015

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