Information Collection

Smoking Cessation Clients Demographic & Customer Satisfaction Questions

IC 219411 under ICR 201807-0925-001 · OMB 0925-0208.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0208 can be found here:

Documents and Forms

Document Name Document Type
Form 4 Smoking Cessation Clients Demographic & Customer Satisfaction Questions Form
4 Smoking Cessation Clients Demographic & Customer Satisfa Appendix 9 Customer Satisfaction Survey Questions.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Smoking Cessation Clients Demographic & Customer Satisfaction Questions	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	4	Smoking Cessation Clients Demographic & Customer Satisfaction Survey Questions	Appendix 9 Customer Satisfaction Survey Questions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 676	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	676	-3,319	3,995
Annual IC Time Burden (Hours)	23	-110	133
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.