Smokefree 60+ Intercept Survey

Formative Research, Pretesting, and Customer Satisfaction of NCI's Communication and Education Resources (NCI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0046 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Smokefree 60+ Intercept Survey Form and Instruction
1 Survey Attachment 1 Survey.pdf Form and Instruction
Mini SSA Smokefree 60+.docx Mini SSA Smokefree 60+ IC Document
Mini SSB Smokefree 60+.docx Mini SSB Smokefree 60+ IC Document
Attachment 2 Question Skip Pattern.pdf Question Skip Pattern IC Document

Information Collection (IC) Details

IC Title:	Smokefree 60+ Intercept Survey	Agency IC Tracking Number:

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	Survey	Attachment 1 Survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	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	3,000	3,000
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Mini SSA Smokefree 60+	Mini SSA Smokefree 60+.docx	10/28/2016
Mini SSB Smokefree 60+	Mini SSB Smokefree 60+.docx	10/28/2016
Question Skip Pattern	Attachment 2 Question Skip Pattern.pdf	10/28/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.