Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)

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⚠️ Notice: This information collection may be referencing outdated material.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
Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese) Form
ASQ Questionnaire - Chinese F-1 NQDW_ASQ_Intake Questionnaire_CHINESE_OMB_CLEAN.docx Form
ASQ Questionnaire - Korean F-2 NQDW_ASQ_Intake Questionnaire_KOREAN_CLEAN.docx Form
ASQ Questionnaire - Vietnamese F-3 NQDW_ASQ_Intake Questionnaire_VIETNAMESE_OMB_CLEAN.docx Form

Information Collection (IC) Details

IC Title:	Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	ASQ Questionnaire - Korean	F-2 NQDW_ASQ_Intake Questionnaire_KOREAN_CLEAN.docx	Yes	Yes	Fillable Fileable
Form	none	ASQ Questionnaire - Vietnamese	F-3 NQDW_ASQ_Intake Questionnaire_VIETNAMESE_OMB_CLEAN.docx	Yes	Yes	Fillable Fileable
Form	none	ASQ Questionnaire - Chinese	F-1 NQDW_ASQ_Intake Questionnaire_CHINESE_OMB_CLEAN.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,935	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,935	1,132	803
Annual IC Time Burden (Hours)	323	189	134
Annual IC Cost Burden (Dollars)	8,708	8,708	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.