NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves

National Quitline Data Warehouse

OMB: 0920-0856

IC ID: 193100

Information Collection (IC) Details

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NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form none Intake Questionnaire E-1 NQDW_Intake_Questionnaire.docx Yes Yes Fillable Fileable

Health Illness Prevention

 

488,846 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 488,846 0 0 10,208 0 478,638
Annual IC Time Burden (Hours) 81,474 0 0 1,701 0 79,773
Annual IC Cost Burden (Dollars) 2,199,807 0 571,950 1,627,857 0 0

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

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