Smoking Cessation "Intake" Questions

Collection of Customer Service, Demographic and Smoking/Tobacco Use Information from NCI's Contact Center, Cancer Information Service (CIS) Clients (NCI)

Documents and Forms

Document Name Document Type
Form 3 Smoking Cessation "Intake" Questions Form and Instruction
3 SCIF with screen shots Appendix 1C SCIF with Screen Shots_2021.docx Form and Instruction
3 SCIF with screen shots Appendix 1C SCIF with Screen Shots_2021.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Smoking Cessation "Intake" Questions	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	SCIF with screen shots	Appendix 1C SCIF with Screen Shots_2021.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-25-0156, “Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service	FR Citation: 67 FR 60742

Number of Respondents: 2,888	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	2,888	-492	3,380
Annual IC Time Burden (Hours)	289	-49	338
Annual IC Cost Burden (Dollars)	0	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.