Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)

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⚠️ Notice: This information collection may be referencing outdated material.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
Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese) Form and Instruction
NQDW Intake Questionnaire - Chinese Complete E-1 NQDW_ASQ_Intake Questionnaire_CHINESE_03_18_2016.docx Form and Instruction
NQDW Intake Questionnaire - Korean Complete E-2 NQDW_ASQ_Intake Questionnaire_KOREAN_03_18_2016.docx Form and Instruction
NQDW Intake Questionnaire - Vietnamese Complete E-3 NQDW_ASQ_Intake Questionnaire_VIETNAMESE_03_18_2016.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 - Chinese Complete	E-1 NQDW_ASQ_Intake Questionnaire_CHINESE_03_18_2016.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	NQDW Intake Questionnaire - Korean Complete	E-2 NQDW_ASQ_Intake Questionnaire_KOREAN_03_18_2016.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	NQDW Intake Questionnaire - Vietnamese Complete	E-3 NQDW_ASQ_Intake Questionnaire_VIETNAMESE_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: 803	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
Annual Number of Responses for this IC	803	803
Annual IC Time Burden (Hours)	134	134
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.