Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire

National Quitline Data Warehouse

Documents and Forms

Document Name Document Type
Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire Form and Instruction
ASQ 7-month Follow-up Questionnaire (Chinese) 0856 NQDW Att E1_NQDW_ASQ_7-month follow-up questionnaire_CHINESE.docx Form and Instruction
ASQ 7-month Follow-up Questionnaire (Chinese) 0856 NQDW Att E1_NQDW_ASQ_7-month follow-up questionnaire_CHINESE.docx Form and Instruction
ASQ 7-month Follow-up Questionnaire (Korean) 0856 NQDW Att E2_NQDW_ASQ_7-Month follow-up questionnaire_KOREAN.docx Form and Instruction
ASQ 7-month Follow-up Questionnaire (Korean) 0856 NQDW Att E2_NQDW_ASQ_7-Month follow-up questionnaire_KOREAN.docx Form and Instruction
ASQ 7-month Follow-up Questionnaire (Vietnamese) 0856 NQDW Att E3_NQDW_ ASQ_7-Month follow-up questionnaire_VIETNAMESE.docx Form and Instruction
ASQ 7-month Follow-up Questionnaire (Vietnamese) 0856 NQDW Att E3_NQDW_ ASQ_7-Month follow-up questionnaire_VIETNAMESE.docx Form and Instruction
ASQ 7-month Follow-up Questionnaire (English translation 0856 NQDW Att E4_NQDW_ ASQ_7-Month follow-up questionnaire_ENGLISH.docx Form and Instruction
ASQ 7-month Follow-up Questionnaire (English translation 0856 NQDW Att E4_NQDW_ ASQ_7-Month follow-up questionnaire_ENGLISH.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	ASQ 7-month Follow-up Questionnaire (Chinese)	0856 NQDW Att E1_NQDW_ASQ_7-month follow-up questionnaire_CHINESE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	ASQ 7-month Follow-up Questionnaire (Korean)	0856 NQDW Att E2_NQDW_ASQ_7-Month follow-up questionnaire_KOREAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	ASQ 7-month Follow-up Questionnaire (Vietnamese)	0856 NQDW Att E3_NQDW_ ASQ_7-Month follow-up questionnaire_VIETNAMESE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	ASQ 7-month Follow-up Questionnaire (English translation for reference)	0856 NQDW Att E4_NQDW_ ASQ_7-Month follow-up questionnaire_ENGLISH.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 236	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	Previously Approved
Annual Number of Responses for this IC	236	-1,351	1,587
Annual IC Time Burden (Hours)	28	-157	185
Annual IC Cost Burden (Dollars)	744	-4,255	4,999

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.