ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)

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⚠️ Notice: This information collection may be referencing outdated material.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
ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset) Form and Instruction
ASQ Intake questionnaire - Chinese - subset F-4 NQDW_ASQ_Intake Questionnaire_Subset_CHINESE_nm.docx Form and Instruction
ASQ Intake Questionnaire - Korean - subset F-5 NQDW_ASQ_Intake Questionnaire_Subset_KOREAN_nm.docx Form and Instruction
ASQ Intake Questionnaire - Vietnamese - subset F-6 NQDW_ASQ_Intake Questionnaire_Subset_VIETNAMESE_nm.docx Form and Instruction

Information Collection (IC) Details

IC Title:	ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	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 and Instruction	none	ASQ Intake questionnaire - Chinese - subset	F-4 NQDW_ASQ_Intake Questionnaire_Subset_CHINESE_nm.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	ASQ Intake Questionnaire - Korean - subset	F-5 NQDW_ASQ_Intake Questionnaire_Subset_KOREAN_nm.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	ASQ Intake Questionnaire - Vietnamese - subset	F-6 NQDW_ASQ_Intake Questionnaire_Subset_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: 86	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	86	-30	116
Annual IC Time Burden (Hours)	1	-1	2
Annual IC Cost Burden (Dollars)	39	39	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.