Information Collection

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

IC 193100 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.