Information Collection

Smoking Cessation "Intake" Questions

IC 219410 under ICR 202504-0925-001 · OMB 0925-0208.

Documents and Forms

Document Name Document Type
Form 1 Smoking Cessation "Intake" Questions Form
Form 1 Smoking Cessation Intake Questions Smoking Cessation "Intake" Questions Form
1 Smoking Cessation Intake Questions Appendix 1C SCIF with Screen Shots_3-19-25.docx Form
1 Smoking Cessation Intake Questions Appendix 1C SCIF with Screen Shots_3-19-25.docx Form

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Smoking Cessation Intake Questions	Appendix 1C SCIF with Screen Shots_3-19-25.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: 8,839	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
Annual Number of Responses for this IC	8,839	8,839
Annual IC Time Burden (Hours)	884	884
Annual IC Cost Burden (Dollars)	0	0

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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].