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

National Quitline Data Warehouse

⚠️ Notice: This information collection may be referencing outdated material.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 complete) - Callers who contact Quitline for themselves Form
Intake Questionnaire E-1 NQDW_Intake_Questionnaire.docx Form

Information Collection (IC) Details

IC Title:	NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves	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	Intake Questionnaire	E-1 NQDW_Intake_Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 488,846	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	488,846	0	10,208	478,638
Annual IC Time Burden (Hours)	81,474	0	1,701	79,773
Annual IC Cost Burden (Dollars)	2,199,807	571,950	1,627,857	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.