Information Collection

Intake Data for Quitline Clients

IC 199077 under ICR 201108-0920-012 · OMB 0920-0917.

Documents and Forms

Document Name Document Type
Intake Data for Quitline Clients Form
Intake Data for Quitline Clients Appendix 5a_Intake Data for Quitline Clients_81111.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Intake Data for Quitline Clients	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	none	Intake Data for Quitline Clients	Appendix 5a_Intake Data for Quitline Clients_81111.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2	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 Agency Discretion
Annual Number of Responses for this IC	8	8
Annual IC Time Burden (Hours)	2	2
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.