NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves

National Quitline Data Warehouse

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0856 can be found here:

Documents and Forms

Document Name Document Type
NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves Form and Instruction
NQDW Intake Questionnaire - Complete D-1 NQDW_Intake_Questionnaire 03_18_2016.docx Form and Instruction

Information Collection (IC) Details

IC Title:	NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves	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 and Instruction	NA	NQDW Intake Questionnaire - Complete	D-1 NQDW_Intake_Questionnaire 03_18_2016.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 478,638	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	478,638	-32,130	510,768
Annual IC Time Burden (Hours)	79,773	-5,355	85,128
Annual IC Cost Burden (Dollars)	0	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.