12 Week Post Quit Date Questionnaire (Attachment 19)

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

Documents and Forms

Document Name Document Type
Form 5 12 Week Post Quit Date Questionnaire (Attachment 19) Form and Instruction
5 12 Week Post Quit Date Questionnaire Attach19_SFTXT_12WeekSurvey_12062012.docx Form and Instruction

Information Collection (IC) Details

IC Title:	12 Week Post Quit Date Questionnaire (Attachment 19)	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	5	12 Week Post Quit Date Questionnaire	Attach19_SFTXT_12WeekSurvey_12062012.docx		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: 1,088	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	1,088	1,088
Annual IC Time Burden (Hours)	272	272
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.