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NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves
National Quitline Data Warehouse
OMB: 0920-0856
IC ID: 193100
OMB.report
HHS/CDC
OMB 0920-0856
ICR 201903-0920-001
IC 193100
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0856 can be found here:
2022-07-25 - Revision of a currently approved collection
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
View Information Collection (IC)
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
Federal Enterprise Architecture Business Reference Module
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 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
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.