Information Collection

NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else

IC 193099 under ICR 201903-0920-001 · OMB 0920-0856.

⚠️ Notice: This information collection may be referencing outdated material.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
NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else Form
NQDW Intake Questionnaire Subset E-2 NQDW Intake Questionnaire_Subset.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else	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	none	NQDW Intake Questionnaire Subset	E-2 NQDW Intake Questionnaire_Subset.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,217	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	12,217	0	-13,790	26,007
Annual IC Time Burden (Hours)	204	0	-230	434
Annual IC Cost Burden (Dollars)	5,508	10	5,498	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.