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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
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
NA
NQDW Intake Questionnaire - Chinese Complete
E-1 NQDW_ASQ_Intake Questionnaire_CHINESE_03_18_2016.docx
NA
Yes
Yes
Fillable Fileable
Form and Instruction
NA
NQDW Intake Questionnaire - Korean Complete
E-2 NQDW_ASQ_Intake Questionnaire_KOREAN_03_18_2016.docx
NA
Yes
Yes
Fillable Fileable
Form and Instruction
NA
NQDW Intake Questionnaire - Vietnamese Complete
E-3 NQDW_ASQ_Intake Questionnaire_VIETNAMESE_03_18_2016.docx
NA
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:
803
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
803
0
803
0
0
0
Annual IC Time Burden (Hours)
134
0
134
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.