Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire

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⚠️ Notice: This information collection may be referencing outdated material.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) Seven-Month Follow-Up Questionnaire Form and Instruction
NQDW 7-Month Follow-Up Questionnaire - English F-1 NQDW_ ASQ_7-Month follow-up questionnaire_ENGLISH_03_18_2016.docx Form and Instruction
NQDW 7-Month Follow-Up Questionnaire - Chinese F-2 NQDW_ASQ_7-month follow-up questionnaire_CHINESE_03_18_2016.docx Form and Instruction
NQDW 7-Month Follow-Up Questionnaire - Korean F-3 NQDW_ASQ_7-Month follow-up questionnaire_KOREAN_03_18_2016.docx Form and Instruction
NQDW 7-Month Follow-Up Questionnaire - Vietnamese F-4 NQDW_ ASQ_7-Month follow-up questionnaire_VIETNAMESE_03_18_2016.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	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 7-Month Follow-Up Questionnaire - Chinese	F-2 NQDW_ASQ_7-month follow-up questionnaire_CHINESE_03_18_2016.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	NQDW 7-Month Follow-Up Questionnaire - Korean	F-3 NQDW_ASQ_7-Month follow-up questionnaire_KOREAN_03_18_2016.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	NQDW 7-Month Follow-Up Questionnaire - Vietnamese	F-4 NQDW_ ASQ_7-Month follow-up questionnaire_VIETNAMESE_03_18_2016.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	NQDW 7-Month Follow-Up Questionnaire - English	F-1 NQDW_ ASQ_7-Month follow-up questionnaire_ENGLISH_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: 659	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	659	659
Annual IC Time Burden (Hours)	77	77
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.