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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.