Information Collection

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

IC 193099 under ICR 202207-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

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	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 %

table that charts list of burden
	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

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.