Screener Questionnaire (Attachment 9)

The National Cancer Institute (NCI) SmokefreeTXT (Text Message) Program Evaluation

Documents and Forms

Document Name Document Type
Form 1 Screener Questionnaire (Attachment 9) Form and Instruction
1 Screener Attach9_SFTXT_Screener_12062012.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Screener Questionnaire (Attachment 9)	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	1	Screener	Attach9_SFTXT_Screener_12062012.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: SORN #09-25-0156, "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"	FR Citation: 67 FR 60743

Number of Respondents: 10,620	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	10,620	10,620
Annual IC Time Burden (Hours)	885	885
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.