Smoker Follow-up Questionnaire

Evaluation of the National Tobacco Prevention and Control Public Education Campaign

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0923 can be found here:

Documents and Forms

Document Name Document Type
Smoker Follow-up Questionnaire Form
Smoker Followup Att C-2 Smoker Follow-Up Questionnaire_1-6-12.docx Form

Information Collection (IC) Details

IC Title:	Smoker Follow-up Questionnaire	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	Smoker Followup	Att C-2 Smoker Follow-Up Questionnaire_1-6-12.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	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	5,000	5,000
Annual IC Time Burden (Hours)	2,083	2,083
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.