NQDW Quitline Services Survey

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⚠️ Notice: This information collection may be referencing outdated material.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 Quitline Services Survey Form and Instruction
National Quitline Data Warehouse (NQDW) Quitline Service G. NQDW Quitline Services Survey 08OCT2015.docx Form and Instruction
G2. Advance Email for Services Questionnaire.docx G2 IC Document
G3. Reminder Email for Services Questionnaire.docx G3 IC Document

Information Collection (IC) Details

IC Title:	NQDW Quitline Services Survey	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	National Quitline Data Warehouse (NQDW) Quitline Services Survey	G. NQDW Quitline Services Survey 08OCT2015.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	216	4	212
Annual IC Time Burden (Hours)	72	1	71
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
G2	G2. Advance Email for Services Questionnaire.docx	09/19/2012
G3	G3. Reminder Email for Services Questionnaire.docx	09/19/2012

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