Information Collection

Evaluation Surveys for Impaired Driving and Safety Belt Interventions

IC 179366 under ICR 200703-2127-004 · OMB 2127-0646.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2127-0646 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NHTSA 1012 Evaluation Surveys for Impaired Driving and Safety Belt Interventions	Form and Instruction
NHTSA 1012 Iowa Seat Belt Survey 2127-0646 IA Survey.doc	Form and Instruction
NHTSA 1012 Pennsylvania Seat Belt Survey 2127-0646 PA Survey.doc	Form and Instruction
NHTSA 1012 Virginia Seat Belt Survey 2127-0646 VA Survey.doc	Form and Instruction
OMB 2127-0646 Modification for State Surveys (CIOT NEXT GENERATION).doc Additonal Information on State Surveys	IC Document

IC Title:

Evaluation Surveys for Impaired Driving and Safety Belt Interventions

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	NHTSA 1012	Iowa Seat Belt Survey	2127-0646 IA Survey.doc	No	Fillable Fileable
Form and Instruction	NHTSA 1012	Pennsylvania Seat Belt Survey	2127-0646 PA Survey.doc	No	Fillable Fileable
Form and Instruction	NHTSA 1012	Virginia Seat Belt Survey	2127-0646 VA Survey.doc	No	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	16,000	0	0	0	0	0
Annual IC Time Burden (Hours)	2,667	0	0	0	0	0
Annual IC Cost Burden (Dollars)	32,000	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Additonal Information on State Surveys	OMB 2127-0646 Modification for State Surveys (CIOT NEXT GENERATION).doc	03/28/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.