NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else

National Quitline Data Warehouse

Documents and Forms

Document Name Document Type
NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else Form and Instruction
NQDW Intake Questionnaire 0856 NQDW Att D1_NQDW_Intake_Questionnaire_Subset.docx Form and Instruction
NQDW Intake Questionnaire 0856 NQDW Att D1_NQDW_Intake_Questionnaire_Subset.docx Form and Instruction

Information Collection (IC) Details

IC Title:	NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else	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	None	NQDW Intake Questionnaire	0856 NQDW Att D1_NQDW_Intake_Questionnaire_Subset.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 819	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	819	-11,398	12,217
Annual IC Time Burden (Hours)	14	-190	204
Annual IC Cost Burden (Dollars)	369	-5,139	5,508

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.