National Quitline Data Warehouse

Forms and Documents

Document Name	Status
ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset) Form and Instruction	New
Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire Form and Instruction	New
Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese) Form and Instruction	New
NQDW Quitline Services Survey Form and Instruction	Modified
Form F1 Follow-up for Callers who Received a Quitline Service Form and Instruction	Removed
NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves Form and Instruction	Modified
NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else Form and Instruction	Modified
CDC Quitline SS Part A_rev 03 21 2016_OMB_FINAL.docx Supporting Statement A	2016-03-23
H-6 Reminder Email NQDW Quitline Services Survey.docx Supplementary Document	2015-10-09
H-5 Request Email NQDW Quitline Services Survey.docx Supplementary Document	2015-10-09
H-4 Reminder Email_Non-respondents_NQDW_ASQ 7_mo follow up.docx Supplementary Document	2015-10-09
H-3 Request Email to submit NQDW_ASQ 7_mo follow up.docx Supplementary Document	2015-10-09
H-2 Reminder Email for Non-respondents for intake data submsision.docx Supplementary Document	2015-10-09
H-1 Request Email to submit NQDW Intake Questionnaire data.docx Supplementary Document	2015-10-09
I. Sample Table Shells.pdf Supplementary Document	2015-10-09
NQDW_research detrmination.pdf Supplementary Document	2015-10-09
C. Consultants on NQDW.docx Supplementary Document	2015-10-09
B Federal Register Notice.pdf Supplementary Document	2015-10-09
A-2 ARRA of 2009.pdf Supplementary Document	2015-10-09
A-3 ACA Section 4002 PPHF.pdf Supplementary Document	2015-10-09
A-1 PHSA.doc Supplementary Document	2015-10-09
CDC Quitline SS Part B_rev 03 18 2016_OMB_R1.docx Supporting Statement B	2016-03-23

IC Document Collections

IC ID	Document Title	Status
218546	Submission of NQDW ASQ Seven-Month Follow-Up Electronic Data File to CDC Instruction	New
218545	ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset) Form and Instruction	New
218544	Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire Form and Instruction	New
218543	Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese) Form and Instruction	New
204102	Submission of NQDW Intake Questionnaire Electronic Data File to CDC Instruction	Modified
193102	NQDW Quitline Services Survey Form and Instruction	Modified
193101	Follow-up for Callers who Received a Quitline Service Form and Instruction	Removed
193100	NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves Form and Instruction	Modified
193099	NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0856	ICR Reference No: 201509-0920-013
Status: Historical Active	Previous ICR Reference No: 201502-0920-013
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0856
Title: National Quitline Data Warehouse
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/24/2016
	Date Received in OIRA: 10/14/2015
Terms of Clearance: Approved consistent with the understanding that data from tobacco users as gathered by this collection is limited to only those tobacco users who receive services from funded state telephone quitlines. Information gathered are thus not representative of, or generalizable to, the general US population of tobacco users, but only those who contact their state quitlines regarding cessation support services.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved	03/31/2016
Responses	506,656	0	564,621
Time Burden (Hours)	80,709	0	89,035
Cost Burden (Dollars)	0	0	0

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Abstract: CDC is requesting approval for Revisions to the National Quitline Data Warehouse (NQDW) Quitline Services Survey.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 4002 Name of Law: Patient Protection and Affordable Care Act PPHF
   US Code: 42 USC 241 Name of Law: Public Health Service Act
   PL: Pub.L. 111 - 5 1 Name of Law: American Recovery and Reinvestment Act of 2009
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 32383	06/08/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 61211	10/09/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire	NA, NA, NA, NA	NQDW 7-Month Follow-Up Questionnaire - Chinese ,   NQDW 7-Month Follow-Up Questionnaire - Korean ,   NQDW 7-Month Follow-Up Questionnaire - Vietnamese ,   NQDW 7-Month Follow-Up Questionnaire - English
NQDW Intake Questionnaire (English subset) - Callers who contact Quitline on behalf of someone else	NA	NQDW Intake Questionnaire - Subset
NQDW Intake Questionnaire (English complete) - Callers who contact Quitline for themselves	NA	NQDW Intake Questionnaire - Complete
NQDW Quitline Services Survey	NA	National Quitline Data Warehouse (NQDW) Quitline Services Survey
Submission of NQDW Intake Questionnaire Electronic Data File to CDC
Asian Smokers Quitline (ASQ) Intake Questionnaire (Complete Chinese, Korean, Vietnamese)	NA, NA, NA	NQDW Intake Questionnaire - Chinese Complete ,   NQDW Intake Questionnaire - Korean Complete ,   NQDW Intake Questionnaire - Vietnamese Complete
ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	NA, NA, NA	ASQ Intake Questionnaire (Chinese - Subset) ,   ASQ Intake Questionnaire (Korean - Subset) ,   ASQ Intake Questionnaire (Vietnamese - Subset)
Follow-up for Callers who Received a Quitline Service	F1	NQDW 7-Month Follow-Up Questionnaire
Submission of NQDW ASQ Seven-Month Follow-Up Electronic Data File to CDC

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	506,656	564,621	0	-57,965	0	0
Annual Time Burden (Hours)	80,709	89,035	0	-8,326	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Modification in Burden Hours are the result of revisions made to the NQDW Questionnaire and addition of Questionnaire in additional languages.

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Annual Cost to Federal Government: $1,257,220

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/14/2015

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