Evaluation Surveys for Impaired Driving and Safety Belt Interventions

Forms and Documents

Document Name	Status
Form NHTSA 1012 Evaluation Surveys for Impaired Driving and Safety Belt Interventions Form and Instruction	New
2127-0646 NOA 03-08-2007.pdf Supplementary Document	2007-03-08
2127-0646 NOA 06-01-2006.pdf Supplementary Document	2006-06-01
OMB 2127-0646 Modification for State Surveys (CIOT NEXT GENERATION).doc Supplementary Document	2007-03-28
2127-0646 Part B[1].DOC Supporting Statement B	0000-00-00
2127-0646 Part A[1].DOC Supporting Statement A	0000-00-00

IC Document Collections

IC ID	Document Title	Status
179366	Evaluation Surveys for Impaired Driving and Safety Belt Interventions Form and Instruction	New

ICR Details

OMB Control No: 2127-0646	ICR Reference No: 200703-2127-004
Status: Historical Inactive	Previous ICR Reference No: 200702-2127-003
Agency/Subagency: DOT/NHTSA	Agency Tracking No:
Title: Evaluation Surveys for Impaired Driving and Safety Belt Interventions
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 06/28/2007
	Date Received in OIRA: 04/05/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2008	36 Months From Approved	06/30/2008
Responses	24,000	0	24,000
Time Burden (Hours)	4,000	0	4,000
Cost Burden (Dollars)	1,920	0	1,920

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Abstract: These are pre/post telephone surveys to evaluate safety belt mobilizations, impaired driving mobilizations, and belt/alcohol demonstration projects. National, State, and local samples will be used. The terms of clearance further stated that OMB will review the complete specification of each State/Demonstration survey instance within in 15 business days. This request for generic approval contains those State surveys.

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Authorizing Statute(s): None

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:
	70 FR 72500	12/05/2005
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 9858	02/27/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Evaluation Surveys for Impaired Driving and Safety Belt Interventions	NHTSA 1012, NHTSA 1012, NHTSA 1012	Iowa Seat Belt Survey ,   Pennsylvania Seat Belt Survey ,   Virginia Seat Belt Survey

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $576,000

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

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

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: 04/05/2007

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