Information Collection

Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire

IC 218544 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⚠️ Notice: This information collection may be referencing outdated material.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
Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	Form and Instruction
ASQ 7 month follow-up - English G-1 NQDW_ ASQ_7-Month follow-up questionnaire_ENGLISH_nm.docx	Form and Instruction
ASQ 7 month follow-up - Chinese G-2 NQDW_ASQ_7-month follow-up questionnaire_CHINESE_nm.docx	Form and Instruction
ASQ 7 month follow-up - Korean G-3 NQDW_ASQ_7-Month follow-up questionnaire_KOREAN_nm.docx	Form and Instruction
ASQ 7 month Follow-up - Vietnamese G-4 NQDW_ ASQ_7-Month follow-up questionnaire_VIETNAMESE_nm.docx	Form and Instruction

IC Title:

Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	ASQ 7 month follow-up - English	G-1 NQDW_ ASQ_7-Month follow-up questionnaire_ENGLISH_nm.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	ASQ 7 month follow-up - Chinese	G-2 NQDW_ASQ_7-month follow-up questionnaire_CHINESE_nm.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	ASQ 7 month follow-up - Korean	G-3 NQDW_ASQ_7-Month follow-up questionnaire_KOREAN_nm.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	ASQ 7 month Follow-up - Vietnamese	G-4 NQDW_ ASQ_7-Month follow-up questionnaire_VIETNAMESE_nm.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,587

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,587	928	659
Annual IC Time Burden (Hours)	185	108	77
Annual IC Cost Burden (Dollars)	4,999	4,999	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.