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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Quitline Services Questionnaire
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
none
NQDW services questionnaire
G1. NQDW Quitline Services Questionnaire_05-04-10.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
53
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
212
0
0
0
0
212
Annual IC Time Burden (Hours)
25
0
0
0
0
25
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Attachment G2 - Advance email for services questionnaire
G2. Advance Email for Services Questionnaire.docx
05/17/2010
Attachment G3 - Reminder email for services questionnaire
G3. Reminder Email for Services Questionnaire.docx
05/17/2010
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.