Information Collection

Smoking Cessation "Intake" Questions

IC 219410 under ICR 202201-0925-001 · OMB 0925-0208.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0208 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Smoking Cessation "Intake" Questions	Form and Instruction
3 SCIF with screen shots Appendix 1C SCIF with Screen Shots_2021.docx	Form and Instruction
3 SCIF with screen shots Appendix 1C SCIF with Screen Shots_2021.docx	Form and Instruction

IC Title:

Smoking Cessation "Intake" Questions

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 and Instruction	3	SCIF with screen shots	Appendix 1C SCIF with Screen Shots_2021.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-25-0156, âRecords of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service

FR Citation: 67 FR 60742

Number of Respondents: 2,888

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	Previously Approved
Annual Number of Responses for this IC	2,888	-492	3,380
Annual IC Time Burden (Hours)	289	-49	338
Annual IC Cost Burden (Dollars)	0	0	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.