National Quitline Data Warehouse

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
ASQ Intake Questionnaire - Vietnamese - subset	Form and Instruction	Modified	Repair queued
ASQ Intake Questionnaire - Korean - subset	Form and Instruction	Modified	Available
ASQ Intake questionnaire - Chinese - subset	Form and Instruction	Modified	Available
ASQ 7 month Follow-up - Vietnamese	Form and Instruction	Modified	Available
ASQ 7 month follow-up - Korean	Form and Instruction	Modified	Available
ASQ 7 month follow-up - Chinese	Form and Instruction	Modified	Available
ASQ 7 month follow-up - English	Form and Instruction	Modified	Available
ASQ Questionnaire - Vietnamese	Form	Modified	Available
ASQ Questionnaire - Korean	Form	Modified	Available
ASQ Questionnaire - Chinese	Form	Modified	Available
Quitline Services Survey	Form and Instruction	Modified	Available
Intake Questionnaire	Form	Modified	Available
NQDW Intake Questionnaire Subset	Form	Modified	Available
A-5 Comments and Responses_OMB_10012019.docx	Supplementary Document	Uploaded 2019-10-07	Available
I. Sample Table Shells.pdf	Supplementary Document	Uploaded 2019-03-04	Available
H-6. Sample Reminder Email for Non-respondents to the NQDW Quitline Services Survey.docx	Supplementary Document	Uploaded 2019-03-04	Repair queued
H-5. Sample Request Email for the NQDW Quitline Services Survey.docx	Supplementary Document	Uploaded 2019-03-04	Repair queued
H-4. Sample Reminder Email for Non-respondents for ASQ 7_month follow up data.docx	Supplementary Document	Uploaded 2019-03-04	Repair queued
H-3. Sample Request Email for submitting NQDW ASQ 7_month follow up data.docx	Supplementary Document	Uploaded 2019-03-04	Repair queued
H-2. Sample Reminder Email for Non-respondents for intake data submsision.docx	Supplementary Document	Uploaded 2019-03-04	Repair queued
H-1. Sample Request Email for Submitting Summary Caller Intake Data to CDC.docx	Supplementary Document	Uploaded 2019-03-04	Repair queued
D. Consultants on NQDW.docx	Supplementary Document	Uploaded 2019-03-04	Repair queued
A-5 Comments and Responses.docx	Supplementary Document	Uploaded 2019-03-04	Available
A-4 60-Day FRN.pdf	Supplementary Document	Uploaded 2019-03-04	Available
NQDW Part B_01302019.docx	Supporting Statement B	Uploaded 2019-03-04	Available
NQDW Part A_01302019_OMB_responses_CLEAN_10012019.docx	Supporting Statement A	Uploaded 2019-10-07	Available
A-2 ARRA of 2009.pdf	Supplementary Document	Uploaded 2015-10-09	Available
A-3 ACA Section 4002 PPHF.pdf	Supplementary Document	Uploaded 2015-10-09	Available
A-1 PHSA.doc	Supplementary Document	Uploaded 2015-10-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
218546	Submission of NQDW ASQ Seven-Month Follow-Up Electronic Data File to CDC	Instruction	Modified
218545	ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	Form and Instruction	Modified	ASQ Intake Questionnaire - Vietnamese - subset
218545	ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	Form and Instruction	Modified	ASQ Intake Questionnaire - Korean - subset
218545	ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	Form and Instruction	Modified	ASQ Intake questionnaire - Chinese - subset
218544	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	Form and Instruction	Modified	ASQ 7 month Follow-up - Vietnamese
218544	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	Form and Instruction	Modified	ASQ 7 month follow-up - Korean
218544	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	Form and Instruction	Modified	ASQ 7 month follow-up - Chinese
218544	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	Form and Instruction	Modified	ASQ 7 month follow-up - English
218543	Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	Form	Modified	ASQ Questionnaire - Vietnamese
218543	Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	Form	Modified	ASQ Questionnaire - Korean
218543	Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	Form	Modified	ASQ Questionnaire - Chinese
204102	Submission of NQDW Intake Questionnaire Electronic Data File to CDC	Instruction	Modified
193102	NQDW Quitline Services Survey	Form and Instruction	Modified	Quitline Services Survey
193100	NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves	Form	Modified	Intake Questionnaire
193099	NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else	Form	Modified	NQDW Intake Questionnaire Subset

ICR Details

OMB Control No: 0920-0856	ICR Reference No: 201903-0920-001
Status: Historical Active	Previous ICR Reference No: 201509-0920-013
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0856
Title: National Quitline Data Warehouse
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/07/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/30/2019
Terms of Clearance: Approved consistent with the understanding that data from tobacco users as gathered by this collection is limited to only those tobacco users who receive services from funded state telephone quitlines. Information gathered are thus not representative of, or generalizable to, the general US population of tobacco users, but only those who contact their state quitlines regarding cessation support services. Before this ICR is renewed, CDC should continue to work with NAQC and other stakeholders to minimize the burden of this data collection. Additionally, CDC should explore collecting data on non-phone enrollees.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2022	36 Months From Approved	10/31/2019
Responses	504,996	0	506,656
Time Burden (Hours)	82,440	0	80,709
Cost Burden (Dollars)	2,225,892	0	0

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Abstract: Since 2010, the National Quitline Data Warehouse (NQDW) has collected a core set of information from the 50 U.S. states, the District of Columbia, Guam, and Puerto Rico regarding what services telephone quitlines offer to tobacco users as well as the number and type of tobacco users who receive services from telephone quitlines.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 4002 Name of Law: Patient Protection and Affordable Care Act PPHF
   US Code: 42 USC 241 Name of Law: Public Health Service Act
   PL: Pub.L. 111 - 5 1 Name of Law: American Recovery and Reinvestment Act of 2009
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 55548	11/06/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 11100	03/25/2019
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	none, none, none	ASQ Intake questionnaire - Chinese - subset ,   ASQ Intake Questionnaire - Korean - subset ,   ASQ Intake Questionnaire - Vietnamese - subset
Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	none, none, none	ASQ Questionnaire - Chinese ,   ASQ Questionnaire - Korean ,   ASQ Questionnaire - Vietnamese
Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	none, none, none, none	ASQ 7 month follow-up - English ,   ASQ 7 month follow-up - Chinese ,   ASQ 7 month follow-up - Korean ,   ASQ 7 month Follow-up - Vietnamese
NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves	none	Intake Questionnaire
NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else	none	NQDW Intake Questionnaire Subset
NQDW Quitline Services Survey	none	Quitline Services Survey
Submission of NQDW ASQ Seven-Month Follow-Up Electronic Data File to CDC
Submission of NQDW Intake Questionnaire Electronic Data File to CDC

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	504,996	506,656	0	-108	-1,552	0
Annual Time Burden (Hours)	82,440	80,709	0	-36	1,767	0
Annual Cost Burden (Dollars)	2,225,892	0	0	578,791	1,647,101	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Slight changes in burden are due to new estimates of the number of respondent based on recent participation in the program.

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Annual Cost to Federal Government: $1,411,313

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/30/2019

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