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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else
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 D1_NQDW_Intake_Questionnaire_Subset.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:
819
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
819
0
-11,398
0
0
12,217
Annual IC Time Burden (Hours)
14
0
-190
0
0
204
Annual IC Cost Burden (Dollars)
369
0
-5,139
0
0
5,508
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.