Information Collection

Smokefree 60+ Intercept Survey

IC 224204 under ICR 201605-0925-007 · OMB 0925-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0046 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Smokefree 60+ Intercept Survey	Form and Instruction
1 Survey Attachment 1 Survey.pdf	Form and Instruction
Mini SSA Smokefree 60+.docx Mini SSA Smokefree 60+	IC Document
Mini SSB Smokefree 60+.docx Mini SSB Smokefree 60+	IC Document
Attachment 2 Question Skip Pattern.pdf Question Skip Pattern	IC Document

IC Title:

Smokefree 60+ Intercept Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Survey	Attachment 1 Survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Mini SSA Smokefree 60+	Mini SSA Smokefree 60+.docx	10/28/2016
Mini SSB Smokefree 60+	Mini SSB Smokefree 60+.docx	10/28/2016
Question Skip Pattern	Attachment 2 Question Skip Pattern.pdf	10/28/2016

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