Information Collection

Non-smoker Survey - Wave D (English and Spanish)

IC 217194 under ICR 202106-0920-001 · OMB 0920-1083.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1083 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1083 Non-smoker Survey - Wave D (English and Spanish) Form and Instruction
0920-1083 Nonsmoker Survey - Wave D Attachment E-1. Waves A-I Nonsmoker Survey Screenshots 12-5-18 (English).pdf Form and Instruction
0920-1083 Nonsmoker Survey - Wave D Attachment E-1. Waves A-I Nonsmoker Survey Screenshots 12-5-18 (English).pdf Form and Instruction
0920-1083 Nonsmoker Survey - Wave D Spanish Attachment E-2. Waves A-I Nonsmoker Survey Screenshots 6-10-19 (Spanish).pdf Form and Instruction
0920-1083 Nonsmoker Survey - Wave D Spanish Attachment E-2. Waves A-I Nonsmoker Survey Screenshots 6-10-19 (Spanish).pdf Form and Instruction
0920-1083 Nonsmoker Survey Wave D_English 04JUN2021 Waves A-I NonSmoker English.docx Form and Instruction
0920-1083 Nonsmoker Survey Wave D_English 04JUN2021 Waves A-I NonSmoker English.docx Form and Instruction
0920-1083 Nonsmoker Survey Wave D_Spanish 04JUN2021 ATTA~8MX.PDF Form and Instruction
0920-1083 Nonsmoker Survey Wave D_Spanish 04JUN2021 ATTA~8MX.PDF Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Non-smoker Survey - Wave D (English and Spanish)	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 and Instruction	0920-1083	Nonsmoker Survey - Wave D	Attachment E-1. Waves A-I Nonsmoker Survey Screenshots 12-5-18 (English).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1083	Nonsmoker Survey - Wave D Spanish	Attachment E-2. Waves A-I Nonsmoker Survey Screenshots 6-10-19 (Spanish).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1083	Nonsmoker Survey Wave D_English 04JUN2021	Waves A-I NonSmoker English.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1083	Nonsmoker Survey Wave D_Spanish 04JUN2021	ATTA~8MX.PDF	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 833	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	833	833
Annual IC Time Burden (Hours)	277	277
Annual IC Cost Burden (Dollars)	9,721	9,721

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.