Information Collection

NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves

IC 193100 under ICR 202503-0920-037 · OMB 0920-0856.

Documents and Forms

Document Name Document Type
NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves Form and Instruction
NQDW Intake Questionnaire 0856 NQDW Att C1 NQDW Intake_Questionnaire 2025_tracked changes_072025_final.docx Form and Instruction
NQDW Intake Questionnaire 0856 NQDW Att C1 NQDW Intake_Questionnaire 2025_tracked changes_072025_final.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves	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 C1 NQDW Intake_Questionnaire 2025_tracked changes_072025_final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 405,053	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	405,053	405,053
Annual IC Time Burden (Hours)	67,509	67,509
Annual IC Cost Burden (Dollars)	1,825,412	1,825,412

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.