Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)

National Quitline Data Warehouse

Documents and Forms

Document Name Document Type
Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese) Form and Instruction
ASQ Intake Questionnaire (Chinese) 0856 NQDW Att C2_NQDW_ASQ_Intake Questionnaire_CHINESE.docx Form and Instruction
ASQ Intake Questionnaire (Chinese) 0856 NQDW Att C2_NQDW_ASQ_Intake Questionnaire_CHINESE.docx Form and Instruction
ASQ Intake Questionnaire (Korean) 0856 NQDW Att C3_NQDW_ASQ_Intake Questionnaire_KOREAN.docx Form and Instruction
ASQ Intake Questionnaire (Korean) 0856 NQDW Att C3_NQDW_ASQ_Intake Questionnaire_KOREAN.docx Form and Instruction
ASQ Intake Questionnaire (Vietnamese) 0856 NQDW Att C4_NQDW_ASQ_Intake Questionnaire_VIETNAMESE.docx Form and Instruction
ASQ Intake Questionnaire (Vietnamese) 0856 NQDW Att C4_NQDW_ASQ_Intake Questionnaire_VIETNAMESE.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	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)	0856 NQDW Att C2_NQDW_ASQ_Intake Questionnaire_CHINESE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	ASQ Intake Questionnaire (Korean)	0856 NQDW Att C3_NQDW_ASQ_Intake Questionnaire_KOREAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	ASQ Intake Questionnaire (Vietnamese)	0856 NQDW Att C4_NQDW_ASQ_Intake Questionnaire_VIETNAMESE.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,686	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	1,686	-249	1,935
Annual IC Time Burden (Hours)	281	-42	323
Annual IC Cost Burden (Dollars)	7,598	-1,110	8,708

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.