Eligibility Screening

National Survey of U.S. Long-Haul Truck Driver Injury and Health

Documents and Forms

Document Name Document Type
Eligibility Screening Form
Eligibility screening interview Attachment F3 Eligibility Screening Interview revised 08-30-2010.doc Form

Information Collection (IC) Details

IC Title:	Eligibility Screening	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	none	Eligibility screening interview	Attachment F3 Eligibility Screening Interview revised 08-30-2010.doc		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	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.